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Full text of "Principles and practice of American medicine and surgery [electronic resource]"

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THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




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CLASS- 



PRESENTED BY 



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Porsyth5ts J^TLANTA,Q,A. 



PRINCIPLES AND PRACTICE 



OF 



AMEEICAN 



Medicine ^Surgery, 



By S. F. SALTER, M. D., 

PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND CLINICAL MEDICINE 
IN THE COLLEGE OF AMERICAN MEDICINE AND SURGERY. 



ATLANTA, GEORGIA, 1883. 



ATLANTA, GA.: 
Jas. P. Habbison & Co., Pbintees. Publishees and Bindebs. 



Entered according to Aet of Congress, in the year »Wj, by 

S. F. SALTER* M. D., 
In the office of the Librarian of Congress, at Washington 



PREFACE. 



In the absence of any standard text-book on practice, suited to the student 
and practitioner of American medicine, I have undertaken the preparation of 
this volume. Originality in the descriptive text is not claimed. I have had 
access to the works of the leading authors, both home and foreign, and have 
made such extracts as have suited my requirement in making up the definition 
pathology and general description of diseases. In treatment I claim originality, 
having given that which years of practical experience have proved worthy of 
confidence. 

The work is not perfect, but will be of incalculable advantage to the student 
of medicine, especially of the American System ; and to practitioners of every 
school it will commend itself as a work of ready reference. 

S. F. SALTER, M. D. 

Atlanta, Georgia, April, i88j. 



PRINCIPLES AND PRACTICE 



OF 



American Medicine i Surgery 



Principles of Medicine. 



Matter, in all its diversity of character, quality, form and combination, may be 
classed in two great divisions, namely : Organic, and Inorganic Matter. 

Organic Matter includes the two vast kingdoms of nature, the animal and 
vegetable kingdoms. 

Inorganic Matter includes all bodies not possessed of life, and which are 
not endowed with the capacity for life. 

Without organization there cannot be life ; and again, organized bodies, 
though possessed of a capacity for life, require the impression of " stimulants 
to call it into activity." 

"Life is the consequence of the operation of stimuli, or excitants, on organ- 
ized matter." 

" Life is the organism in motion." 

" A proper organization, and suitable temperature, produce life and motion. 
Caloric, or heat, is the cause of life and motion." 

" Caloric, whatever be its nature, is the first and most important of all stimu- 
lants ; and if it ceases to animate the economy, others lose their influence over 
it." 

There is, in an egg, a point of organized matter — a germ endowed with a 
capacity for life. Place the egg in a temperature of 98 degrees of heat, and 
vital movements will commence in the elements comprising the germ. Under 
the stimulating power of heat, the germ is nourished, organs developed, and a 
perfect animal formed. If the egg becomes chilled, vital movement ceases, dis- 
organization and decomposition ensue. 

In the early period of human animal life, heat is derived from the mother ; and 
after birth, heat is generated within the body. The generation of heat within 
the body is as necessary to vital action in man, as external heat is necessary to 
sustain vitality in the chick, before it bursts from the shell. 

It is by the animating power of heat that the system becomes susceptible 
to the impression of other life-supporting agents, as air, light, electricity, galvan- 
ism, food, drinks, and medicine. 

Animals that remain torpid and insensible during winter are re-awakened 
into life and activity on the return of warm weather. Upon the same principle 
the vapor bath proves a powerful auxiliary remedy in the cure of dis- 



6 Principles and Practice of 

ease, by imparting caloric and electricity to the blood ; and in many instances 
of slight ailments, is sufficient of itself to restore to the system the power neces- 
sary to establish health. 

" If the system be deprived of caloric for a certain length of time, all the pre- 
servative, recuperative and sanative phenomena cease. It is the same also as 
respects oxygen." 

Caloric (heat) brings into play the nerve power, (assumed to be an electro- 
galvanic influence) which, operating through the medium of the nervous appa- 
ratus, carries on and governs all the vital functions — respiration, circulation, 
digestion, nutrition, assimilation, etc.; selects and expels effete or worn out 
matter by the pores of the skin, the kidneys, and other depuratory organs; 
carries on all the various secretions ; endows the organs with sensation ; and 
enables the organization to resist the influence of causes that tend to its destruc- 
tion. 

If the premises advanced in the above paragraphs be true, they prove (theo- 
retically) the correctness of the American practice, founded by Dr. S. Thomson f 
which has for its object to promote and sustain the function of calorification, or 
as Dr. Thomson terms it, " the power of inward heat" as a means of aiding the 
vital functions, under the control of the nervous influence, to overcome disease 
and re-establish health. 

It is through the agency of vital energy inseparably connected with the func- 
tions of calorification, that the causes of disease are resisted, and health restored 
when the system is invaded with disease. This is universally true under all 
circumstances, in relation to general disease. 

" While the assimilation of food, in vegetables, and the whole process of their 
formation,,, are dependent on certain external influences which produce motion, 
the development of the animal organism is, to a certain extent, independent of 
these external influences, just because the animal body can produce within itself 
that source of motion which is indispensable to the vital powers. The mutual 
action between the elements of the food and the oxygen conveyed by the circula- 
tion of the blood to every part of the body, is the source of animal Aeat."^ 

A good digestion and a proper supply of food and air, are requisite, not only 
to supply the wastes of the system, but also to produce the amount of heat and 
nervous energy necessary to maintain healthy action in the system. " The 
stomach is the fire-place of the system, and food the fuel that furnishes the heat, 
upon which life and motion depend." It naturally follows that a wholesome, 
nutritious diet is essential to the health. 

'•' The law of organic life is fixed ; it cannot be changed ; but the forces that 
bring this law into activity, heat, electricity and magnetism, are never fixed, but 
are constantly subject to disturbances from perturbating influences." 

The laws of life always operate in the fullest degree of perfection, under the 
attending circumstances. 

To operate in their greatest degree of perfection, or, in other words, to main- 
tain a state of perfect health, it is necessary that all the forces that influence the 
. operation of the laws of life, shall be in the most favorable condition. 

A deficiency in the supply of either aliment, atmospheric air, or heat, and its 



American Medicine and Surgery. J 

associated elements, light, electricity, and magnetism, renders the operation of 
the laws of life imperfect, and necessarily occasions disease. 

Nutrition, the process by which nutritive material is converted into living 
organic structure, is the first vital action, and constitutes, during life, the basis 
of every other vital movement or function. 

Derangement of the nutritive action of an organ, necessarily impairs its func- 
tions. The various functions, digestion, respiration and circulation, subserve 
the purpose of furnishing the necessary supply of nutritive materials ; and calori- 
fication and enervation are the sources of motion. 

Simultaneously with the nutritive or assimilative action, there is a constant 
decomposition process being carried on, by which worn-out material is taken up 
and expelled, mainly by the kidneys and through the pores of the skin. The 
latter constitutes the great outlet of morbific humours from the system; and 
this fact makes manifest the importance of promoting perspiration as a means 
of clearing the system of disease. 

In the inferior animals, and vegetables, the vital actions are capable of sus- 
pension, without their destruction ; the organic force diminishes, but is not en- 
tirely extinguished. On the renewal of stimuli, the vital phenomena again 
reappear, and the organic force is renewed. These facts are seen in hibernating 
animals, and in vegetables in the temperate latitudes, having alternate seasons 
of opposite temperature. 

The abstraction of the stimulus of heat diminishes the vital actions ; the func- 
tions of the various organs essential to life are gradually suspended and almost 
every trace and sign of animation are lost. With the renewal of the stimulus of 
caloric, whether artificial or solar, reanimation commences ; the vital actions 
are reawakened ; they are manifested in their fullest energy; and the organic 
force which had been nearly extinguished, acquires its former intensity. In the 
higher order of animals, and in man, " vital actions once commenced, cannot be 
again suspended for any length of time ; they have different degrees of energy ; 
but if once terminated, or reduced to a certain point, they are not again 1 renewed ; 
their cessation is permanent, and with them cease the organic forces. This 
constitutes death." The human system is endowed with power to react against 
causes that tend to its destruction. The impressions produced by the causes of 
disease being communicated to' the brain by the nerve of sensibility, a recu- 
perative action is instituted, with the design of expelling the cause of disease. 

Nature is the real physician ; in other words, diseases «re cured, wounds 
healed, and injuries repaired by processes of actions or movements under the 
control of the vital principle or laws of life. These curative processes are 
manifested by fever, inflammation, vomiting, diarrhoea, and convulsions. 

So far as we aid nature we do good, but when we give agents at war with the 
natural process, then we do an injury. 

The nervous, or electro-magnetic fluid, which under the vivifying influence of 
caloric, and acting in conformity to the organic laws, is the immediate or proxi- 
mate agent of every vital movement, is generated from red globules of blood, as 
they circulate through the nerve centres. All recuperative, life-sustaining actions 
are carried on through the agency of the nervous fluid. 



8 Principles and Practice of 

The nerves of the internal mucous membrane, especially those of the stomach, 
exercise a controlling influence over the digestive, nutritive, and all other vital 
functions. 

The amount of nerve force generated will be in the same ratio to the quantity 
of red globules of blood circulating through the nerve-centres ; and, conse- 
quently to abstract blood by the lancet, or to prevent its formation by poisonous 
drugs, taken into the stomach, that impair digestion, retards the curative opera- 
tions of nature. 

In disease the digestive functions are either impaired or suspended, and, con- 
sequently, the system is partially or wholly deprived of a supply of the means 
of subsistence from the natural source. 

This important fact, it would seem, has never been taken into consideration 
by medical theorists, inasmuch as their general course of treatment directly 
tends to lessen the amount of blood, or to produce greater prostration of the 
digestive functions. The supply of nutritive material from food being cut off, 
in consequence of a suspension of the digestive functions, vital action soon would 
cease, were it not that nature, but more properly the Author of nature, has pro- 
vided a means for sustaining life by a process of reaction constituting fever. 
The pores of the skin are " locked up," retaining the heat ; the action of the 
heart is quickened, giving increased impetus to the circulation of the blood 
through the nerve-centres, to sustain the various functions ; and being impelled 
through the lungs more rapidly, with a corresponding increase of respiration, 
the blood thereby becomes more highly vitalized, and better adapted to sustain 
the recuperative actions necessary to overcome the influence of the cause of the 
disease. In malignant forms of disease, for instance in that class termed "■ con- 
tinued fevers," the life of the patient depends upon the continuance of the recu- 
perative action — the fever — until a favorable crisis is effected. 

It is by action — by vital movement — that disease is overcome. 

The direct tendency of cold, poison, and other causes of disease, is to suspend 
vital motion, weakening the power that sustains nutrition or vital chemistry. 

The lower order of animals, those not endowed with the power to react, 
never have fever, neither can inflammation be established in them ; whereas in 
the higher order and in man the brain is made to know of the existence of dis- 
ease, and establishes a recuperative process constituting fever and inflamma- 
tion. Hence most of the symptoms of disease are the result of the protective 
power of the economy in operation — the efforts of the system to sustain itself, 
and to throw off the disease. 

The most fatal cases of disease are those unattended by fever ; for instance 
in small-pox and scarlet fever, the specific poison producing the disease ope- 
rates, in some cases, with such deadly power, that the vital forces are at once 
prostrate below the point to admit of reaction ; the patient remaining cold and 
partly insensible from the commencement of the disease, until the spark of life 
is extinguished. 

The cold plague, as it was termed, which proved so alarmingly fatal in some 
parts of the old world, was characterized by coldness and absence of fever. This 
was also a peculiar feature of the Asiatic or epidemic cholera — the function of 



American Medicine and Surgery. 9 

nutrition, and, consequently, that of calorification and enervation, being, in many 
cases, suspended in the very outset of the disease. 

The amount of vital power in the system is always less in disease than it i9 
in health. 

In fever of even the highest grade, there is always a diminution of the life- 
power— nature fans the fire of life by forcing the blood through the lungs at 
increased ratio, and quickening the respiratory movements. 

These are the means furnished by the Creator to supply the necessary wants 
of the system, when the stomach cannot digest food. 

The stomach is trie great repository from which the body receives its sup- 
port, and- its condition exerts a widely extended influence over the system. Be- 
ing the recipient organ for all food, drinks and medicines, and from its " central 
and exposed position and extraordinary sympathies," this organ is extremely 
liable to become disordered and its functions impaired from many sources, and 
seems to be the organ which is first affected in nearly every variety of disease. 
While the functions of the stomach remain unimpaired, the causes of disease 
are repelled, but when suspended or impaired from any cause whatever, the se- 
cretions become vitiated, the circulation flags, the nutritive action diminished, 
and the animal temperature lowered. 

These conditions are the immediate consequences of disorder or suspension 
of the functions of the stomach. 

Under favorable circumstances and conditions, nature will rally and bring in- 
to operation a counteracting influence for the preservation of the system, consti- 
tuting the recuperative processes previously described. The influence of cold 
in engendering disease may be traced to its prostrating effects upon the digestive 
and nutritive functions. 

Food taken into the stomach, unsuited to the state of the digestive functions, 
is a common source of disease. Food remaining undigested in the stomach 
becomes an enemy to health; and at particular seasons, and under certain condi- 
tions, actively poisonous agents are formed by chemical changes taking place be- 
tween the elements of food an d the acrid secretion of the stomach producing 
cholera morbus, epidemic cholera, malignant dysentery, etc. 

At seasons when an epidemic disease is prevailing inaccuracies in diet form a 
very common exciting cause of the disease in those predisposed to it. 

Vomiting, and all other disease expelling and curative actions, are instituted 
and carried on by a power generated at the base of the brain — the medulla ob- 
longata. This is the seat or throne of power, whence proceed the commands 
for all movements designed to protect the system from disease. The nerve cen- 
tres throughout the system, apprise the great centre of the condition and wants 
of the system through the medium of the nervous cords, which may be com- 
pared to telegraph wires. 

The great centre, taking cognizance of the intelligence thus conveyed, com- 
mands the movement within its control best adapted to overcome enemies and 
supply existing wants. 

Thus, the infant stomach, oppressed by too much food, or disturbed by the 
presence of foul or acrid substances, is relieved by vomiting. 



to Principles and Practice of 

The knowledge of the condition of the stomach being telegraphed to the base 
of the brain through the medium of sensitive nerves, vomiting is induced, and 
this is a provision of nature to relieve the stomach. 

A badly organized stomach, or one in which the nerves or sensibilities are not 
in a condition to convey to the brain the knowledge of the presence of acrid 
substance will be subjected to pain and distress in consequence of the transmis- 
sion of the acrid materials from the stomach to the bowels, there producing an 
effect which calls for reaction to expel the acrid substances. 

In medicine, error in theory leads fo error in practice. 

The physician, educated to regard fevdr as constituting disease, and the in- 
creased action of the heart and the arteries, necessary to sustain the curative 
actions, as excess of vital power, is led to practice blood-letting, blistering, purging 
and to prescribe antimony, nitre, calomel, digitalis and various other poisonous 
agents, with a view to moderate or suppress those actions; and notwithstanding 
the evil consequences of such practice, the same course of treatment is pursued 
as long as the theory, by which the practice is governed, is believed to be true. 

Nature always conducts her operations for eradicating disease in the best way 
possible, with the resources furnished by internal and external conditions and 
circumstances. Every movement, whether voluntary or involuntary, is attended 
with an expenditure of nervous fluid derived from arterial red blood. Active 
exercise demands an active circulation of the blood through the nerve centres, 
which generate the nerve force requisite to produce muscular action. One in 
Whose system there is a deficiency of red blood will, in ascending a flight of 
stairs, experience an increase in the action of the heart to probably 160 or 180 
beats per minute ; this increased action being absolutely and essentially neces- 
ary, in order to generate power to perform the required exertion. 

The exercise of running is accompanied by a more violent action of the heart, 
otherwise the muscular action required could not be performed. 

In disease, whenever the action of the heart is augmented, there exists a ne- 
cessity for it. 

Thus in fever, inflammation, extreme debility, etc., its energy is invoked for 
the accomplishment of an object or design, ultimately for the preservation of 
the system. Physicians should study the designs of nature and endeavor to as- 
sist her efforts. 

Medical treatment, to prove beneficial, must harmonize with the principle of 
life. Pain may be relieved by stupefying the brain with narcotics ; fever may be 
subdued by prostrating the vital powers ; the heart's action may be lessened by 
the administration of digitalis and other sedatives; and inflammatory action may 
be reduced by cathartics and general depletion; but such treatment operates al- 
ways against nature, directly and invariably tending to deprive the system of 
the means to support and to weaken its power of resisting the cause of disease. 
" Physicians," observes a celebrated teacher of medicine, "has always looked at 
the outside of disease, and have been doctoring symptoms without understand- 
ing the nature of disease." 

Perfect health may be defined to be that state in which external and internal 
"conditions and influences are favorable to the free and undisturbed operation of 



American Medicine and Surgery. 11 

the laws of life ; that condition of the living body in which all the vital, natural 
and animal functions are performed easily and perfectly and unattended with 
pain. 

It consists in a natural and proper condition and proportion in the functions 
and structure in the several parts of which the body is Composed. 

From physiology we learn that there are certain relations of these functions 
and structures to each other and to ex'ernal agents, which are most conducive 
to their well being and permanency, which constitute the condition of health. 
States, which are deviations from the due lftlance between the several proper- 
ties or parts of the animal frame, constitute disease. The most perfect state of 
health is generally connected with a certain conformation and structure of the 
bodily organs, and well marked by certain external signs and figures; a well 
proportioned body, calm and regular circulation of the blood, free and full res^ 
piration, easy digestion, etc. 

Disease consists essentially in diminished vital power. Man's body resembles 
a stately mansion, constructed of beautiful but very perishable materials, all of 
which are needing repairs to keep up the shape and utility of the building. But 
not all in equal degrees; some portions may stand unaided for years, while others 
may need hourly looking after. When the occupant leaves the building re- 
pairs cease, and then we see all the materials, one by one, falling into ruin. 
What, then, raises to the rank of living creatures* and clothes with loveliness, 
the masses of organic matter which are growing, moving, breathing, thinking 
all around us ? 

It is the power of the individual life to create its own individual form. It is 
the form which constitutes the self. 

The organic materials are the property of the form only so long as it retains 
them, and no longer — they are a floating capital. Over the innate essential ele- 
ments it has no control. Life cannot make the brute materials which it uses 
live longer than that which it leaves unused, but it has the power of making 
them anew ard building them up into a certain shape for the time they are made 
to last. 

In short, life rests on the metamorphosis, or renewal of the body, as this re- 
newal is more thorough, the individual is more perfect, if it stops altogether, the 
body is no longer living. If it partially stops there is disorder, or what we call 
disease. Health is the perfect harmony of the human mechanism — a super- 
abundance of life — an excess of vital action cannot exist. 

We cannot have a too active metamorphosis of the tissues, for the freshef 
their organic constituents, the more serviceable they are, incessant change is the 
organic law. 

The most active metamorphosis of the body possible, the highest possible de- 
velopment of life, is health. The complete cessation of the metamorphosis is 
death. The partial cessation or arrest is disease. In death the flesh goes on 
decomposing as during life, but there being no renewal the form is lost. In 
disease waste goes on, perhaps more rapid, but renewal fags, incomplete or de- 
generate tissue are formed. 

Equilibrium of the vital forces depends upon perfect harmony of two forces 



12 Principles and Practice of 

carried on simultaneously; destruction and construction both are necessary, 
there must be no deficiency of either, for a preponderance of one over the other 
in any part, or a deficiency, constitutes a deficiency of life, (a disease) an ab- 
sence of health. To overcome this deficiency of life is the sole aim of treatment 
of disease; to ascertain how vital functions can be increased or diminished; how 
a balance can be maintained is the sole object of the physician. 

Symptoms do not constitute disease. They are the immediate consequence 
of diminished vital power, or they may arise from the restoring efforts of the 
constitution. Thus the first symptoms in disease, as languor and debility, cold- 
ness of the surface and chilliness are the immediate effects of a loss of vital 
power, whereas when re-action takes place many of the accompanying symp- 
toms, as fever, pain, inflammation, vomiting, diarrhoea and convulsions, are the 
consequences of the vital force resisting the cause of disease. 

Disease is produced by agents or causes which exert an influence upon the 
system not congenial to the vital principle, or which are not in relation with 
or adapted to the laws of life. 

Exposure to cold and dampness; sudden vicissitudes of temperature, more es- 
pecially when the system is in an exhausted condition; exclusion from the open 
air and close confinement to business; unwholesome food taken into the stom- 
ach; excesses in eating and drinking, and in the indulgence of the animal pas- 
sions; and specific, poisonous agents, such as produce small-pox, measles and 
scarlet fever, are the general sources of disease. Cold and dampness are fruit- 
ful sources of disease. Their direct effect upon the system is to weaken the 
vital power, and consequently diminish and subvert the healthy order of action 
in the system, and whatever organ or part of the body is weakest, proportion- 
ately to its natural degree of vitality, that will be the part most likely to become 
diseased. Hence, of any number of persons exposed to cold and dampness, 
each may have a different form of disease. 

Thus one may have a pleurisy, another rheumatism, a third a simple catarrh, 
a fourth quinsy, a fifth bronchitis, a sixth neuralgia, a seventh sick headache, 
whilst another may be taken with bilious fever, and another with erysipelas. In 
this way almost every variety of disease may be brought on by the same cause. 

Marsh miasmata. The poisonous effluvia, or vapor, arising from decompo- 
sition of vegetable matter, together with cold and dampness, are believed to be 
the principle cause of the fevers that prevail during the latter part of summer 
and in autumn, more particularly in low, marshy districts of country. It is cer- 
tainly true that fevers prevail most in marshy places and near ponds of stag- 
nant water . Newly cleared land evidently gives rise also to noxious vapors 
from the decomposition that ensued on the exposure of the fresh earth to the 
sun. This will account for the prevalance of disease in newly settled places. 
The first effect of this miasmata upon the system is to weaken the vital powers. 
The strength becomes enfeebled; the appetite fails; there are languor, chilliness 
and aching pains — precisely such symptoms as might be produced by exposure 
to cold and dampness. These symptoms are the direct consequence of the 
poisonous effluvia weakening vitality, and as the constitution rallies to expel the 
poison, fever is produced. 



American Medicine and Surgery. 13 

The greater part of medicines employed by other systems of practice have no 
relation to the laws of life, but are repugnant to nature and injurious to the 
constitution. Such agents will modify symptoms or change the form of disease, 
but often where a cure is effected it is the result of the sanative efforts of the 
constitution, in spite of medicine. 

When fever prevails it furnishes evidence of the existence of an offending 
cause in the system, and the treatment instituted should have for its object the 
removal of that cause. Thus an emetic will in many instances dispel fever by 
evacuating the stomach of acrid secretionsfrand undigested food, from which 
cause so frequently proceed febrile symptoms, more especially during infancy 
and childhood. 

Dr. Samuel Thomson, in his " Remarks on Fevers, " says : — " What is com^ 
monly called a fever is the effect and not the cause of disease. It is the struggle 
of nature to throw off disease. 

"The cold causes an obstruction and fever arises to remove it. This is uni- 
versally the case. Remove the cause and the effect will cease. " This theory 
of fever advanced by Dr. Thomson, and doubtless original with him, was main- 
tained by Hypocrates, Sylvius and others of the early writers on medicine. 

But the failure of their practice arose from the employment of remedies 
which tended to aggravate rather than assist the efforts of nature. The Ameri- 
can practice is the only system that has ever made the proper distinction be- 
tween pure stimulants, which raise and support vital action, and those which 
provoke an unnatural action and ultimately exhaust the strength. It is to the 
founder of this system we are indebted for the discovery and selection of medi- 
cines which harmonize with the laws of life, and if judiciously applied are 
adapted to the cure of every variety of disease. 

Where a patient is treated upon the rule of contraries, where one irritation is 
set up to correct another, we have both the disease and the doctor to contend 
with. Anything calculated to reduce the vital powers, whether it is the lancet 
of the old fogy or the depleting blisters and purgatives of latter day practition- 
ers, is contrary to natural laws and tends to lessen the chances of recovery. 

This plan of treatment would make a well man sick, and, continued long 
enough, produces exhaustion of all the vital powers. This being true no prac- 
tice that ignores the workings of nature can be successful in the treatment of 
disease. 

The specific Medicationist, the expectant Homeopathist and the contrary Al- 
lopath will alike fail in the management of disease. 

When they destroy the vital or heat producing powers of the patient in fever 
they but add to the power of the germ, or poison, and instead of aiding the pa- 
tient, aid the destructive process. When we keep up the inward heat above 
the outward we aid the vital powers to throw off the cause of the fever. In 
tracing the progress of fever to a favorable crisis we find it terminating in a res- 
toration of the secretions, and by establishing some critical evacuation, more 
particularly by perspiration and urine. 

This fact points out the design of nature in establishing fever or re-action. 

The American system of practice will assist the continual effort infringing 



14 Principles and Practice of 

on a re-action. But take a case of remittent fever, bleed this patient every day, 
put him on low diet, purge with active cathartics, give him freely of ice water 
to drink, and pursue this course for a week, and in nine cases out of ten the 
fever will at the end of this time assume a malignant type, and the patient very 
probably die, in consequence of the system being deprived by the treatment of 
the power to' resist disease. 

It is by reaction, or the power of vital resistance, that the organization is 
sustained against all debilitating causes. Dr. Parrish, in lecturing his class re- 
lated the case of a man who had l|een for a length of time subject to frequent 
losses of blood from piles, and subsequently underwent an operation by which 
he lost a large quantity of blood. This, in a few days after the operation, threw 
the system into a state of tumultuous excitement — the face red, eyes sparkling, 
with a full, bounding pulse and the carotid arteries throbbing very strongly, 
and, as the doctor stated, the patient exhibited symptoms which every surgeon 
would have believed demanded bleeding, when at the same time the patient was 
drained of almost all his blood. 

Not many years ago one of the surgeons in Blockly Hospital, a man of exten- 
sive experience, having been fourteen years in practice, on examining a patient 
in one of the wards, inquired of one of the house physicians why that patient 
had not been bled, and immediately directed a pint of blood to be drawn. 

The doctor was informed, however, that this patient had a surgical operation 
performed a few days previous, and that secondary hemorrhage had taken place 
and the patient had been already nearly bled to death. 

The frequent abstraction^ blood has repeatedly produced symptoms of in 
flammation of the brain, and the arterial system thrown into a state of great 
excitement, presenting the same symptoms which, according to the doctrines of 
the schools of medicine, require the use of the lancet, the loss of blood being, at 
the same time, the sole cause of the excitement ; the constitution reacting 
against the threatening danger arising from the loss of blood. Often has in- 
flammation of the brain ensued -in remittent fever, and the disease assumed a 
malignant character by bleeding or purging, or by both, reducing vitality so low 
that nature has been driven to rally all her powers to " save a wreck," the clash- 
ing forces struggling for the ascendency, which, too often, is decided in favor of 
the foe to life, aided by this irrational plan of treatment. 

Excessive loss of blood is not always followed, however, by reaction ; in some 
instances, the system remaining in a state of debility, accompanied by some 
chronic disorder, as dyspepsia, liver complaint, consumption, dropsy, etc. 

" In disease of the constitution, fever is nature's handmaid. In local disease 
her chief reliance is upon inflammation." 

Inflammation is required in the healing of wounds. Blood furnishes the ma- 
terial for repairing injuries, and its presence is also necessary for sustaining vi- 
tality in parts surrounding an injury. A splinter lodged in the flesh and allowed 
to remain, creates a necessity for inflammation in order to effect suppuration, 
the means by which bodies become detached and separated from living tissues. 
The poison from a bee-sting occasions severe pain ; blood is sent quickly to the 
part, and there deposits coagulated lymph, blocking up the cells of the cellular 



American Medicine and Surgery. 15 

tissue, for the purpose of preventing the poison being absorbed and carried into 
the circulation. If the poison be neutralized by the application of ammonia, 
then there will be no occasion for inflammation. 

If from exposure to cold and dampness, or from any other cause, an obstruc- 
tion takes place in the capillary vessels of the pleitra, the knowledge of this con- 
dition is communicated to the brain ; the energies of the heart and arteries are 
invoked ; the blood rushes to the part to overcome the tendency to disorganiza- 
tion ; and if the circulation be restored there will be no necessity for inflamma- 
tion. If, however, the reaction fail of removing the obstruction, inflammation is 
the next step taken in the curative process ; which, under the most favorable cir- 
cumstances, will terminate in resolution ; or, if this cannot be affected, there 
will be an effusion of serum, or an exhalation of lymph, or the inflammation 
may terminate in the formation of pus, in consequence of the loss of vitality in 
the pleura. 

Inflammation of the brain, as it frequently occurs, as a consequence of exhaust- 
ion of vitality in the complaints of children, is the protective power of the econ- 
my in operation to sustain the vitality of the brain, and if the designs of nature, 
in establishing inflammation be accomplished, the crisis will be favorable. In 
hip disease, the condition of the parts make it necessary that inflammation shall 
be established. 

The vitality of the diseased parts cannot be preserved without inflammation, 
and, under favorable circumstances and correct treatment, the inflammation may 
terminate in resolution, and the parts be restored to a healthy condition. Under 
circumstances less favorable, there will be anchylosis of the joint — the joint 
becoming stiff. This is, next to resolution, the most favorable termination of the 
recuperative action. If the vitality of the tissues cannot be preserved by the re- 
storative effort, suppuration becomes necessary ; — the dead parts become sepa- 
rated from the living parts by the suppurative inflammation. Sometimes the 
head of the bone loses its vitality, requiring it to be removed by a slow process 
of suppuration, or caries, effected by an inflammatory action. 

Inflammation of the bowels, as it occurs, for instance in dysentery, is estab- 
lished for the purpose of preserving the vitality of the mucous membrane. The 
most fatal cases of dysentery are those unattended by any marked symptoms of 
inflammation ; — the violence of the cause of the disease producing disorganiza- 
tion of the mucous membrane in the outset of the disease. The death of the 
parts in fatal cases of dysentery is not the consequence of the inflammation. 

The condition of the lungs at the time tubercles are deposited, is the opposite 
to inflammation. When the tubercles become enlarged, nature establishes an 
inflammatory action around the tubercles for the purpose of bringing about sup- 
puration, the only way by which tuberculous matter can be removed from the 
lungs. 

If a dose of violent poison, such as arsenic, prussic acid, opium, or veratrum, 
be taken in sufficient quantity to cause death, in the course of a few hours there 
will be no marks of inflammation in the stomach after death. The vital princi- 
ple will be destroyed before any curative effort can be established. If a portion 
of bone loses its vitality, either by the use of mercury, or other poison, or from 



1 6 Principles and Practice of 

scrofula, inflammation is absolutely necessary, in order to remove the diseased 
bone, and to repair the injury by the deposition of new bone. When the vital- 
ity of a bone is not too far reduced, it may be restored to a healthy condition by 
means of inflammation. A broken bone cannot unite without inflammation. 

Cases have occurred where broken bones have been prevented from uniting 
by bony union, in consequence of the parts having been frequently subjected to 
motion, breaking up the knitting of the bone, until finally the inflammation has 
subsided, and the parts not being supplied with sufficient blood to furnish the 
material and sustain the action necessary to unite the broken bone, a false joint 
has been formed. 

Dr. Physic devised a plan for effecting a reunion of the bone in such cases, by 
forcing a threaded needle through the limb,between the surfaces of b r oken bone, 
and leaving the thread in the part, for the purpose of exciting inflammation, and 
thus furnish the means necessary for a reunion of the bone. Although inflamma- 
tion be a restorative action.it is liable to become perverted into an unhealthy one» 
and the accomplishment of the object for which it is instituted prevented. 

Thus, if a person of scrofulous constitution, or whose system is in an other- 
wise unhealthy condition, should receive a bruise which destroys the vitality of a 
portion of flesh, the inflammation that ensues will be extremely liable to assume 
an unhealthy character, the efforts of nature being too feeble to establish healthy 
inflammation, and instead of being circumscribed, as in case of a boil, it may 
spread over a considerable extent of surface, forming what is called erysipelas ; 
and when matter is formed in the injured part instead of being confined to the 
spot where it is secreted, as it is when the inflammation is of a healthy character, 
it spreads to a greater or less extent through the surrounding parts which be- 
come swollen, doughy, and without extra heat attending, and may require a long 
time for the parts to become restored to a healthy condition, in consequence of 
the want of power in the system to establish an efficient inflammatory action. 
A simple incision in the flesh from a sharp instrument that heals rapidly in a 
healthy constitution may become converted into an indolent ulcer in one of an un- 
healthy constitution. An injury upon the shin that would be followed by 
healthy inflammation, and the part restored to a healthy condition in a short 
time, in a young man.would be apt to become converted into an indolent ulcer, and 
probably continue for years in an old man of feeble health. The healing power is 
sometimes almost destroyed in constitutions poisoned by the use of mercury, 
the simple scratch of a pin causing a long continued running sore. Blisters have 
occassionally been observed to become gangrenous in consequence of extreme 
prostration of the healing powers of the system ; the constitutional energies 
becoming too far exhausted to establish healthy inflammation, and to sustain 
the action necessary to heal the parts. 

Inflammation may assume an unhealthy character in consequence of the se- 
verity of an injury. This fact is frequently noticed in gun-shot wounds, the 
surrounding tissues being deadened by the force of the concusssion, the vessels 
of the parts have not sufficient power to carry on a healthy inflammatory or re- 
storative action. 

" Let us suppose," observes Astley Cooper, " that two women, each receives a 



American Medicine and Surgery. iy 

blow on the breast, one with a vigorous and healthy constitution, and the other 
with a system worn down with care, anxiety and disappointment, and in a state 
of chronic, feverish excitement, in which the secretions are imperfectly perform- 
ed, and is thus predisposed to the formation of cancer. In the first individual, 
the inflammation will be strictly healthy, going through its several stages until 
the cure is accomplished ; but in the other, owing to constitutional peculiarity, 
the same extent of injury will produce cancerous disease, an affection over which 
all remedies hitherto tried have little control, and extirpation is but an uncertain 
mode of relief." 

Inflammation in internal organs is no less curative in design than when it is 
confined to external parts of the body. Poison, taken into the stomach, is fol- 
lowed by inflammation of its mucous membrane, unless the dose be so large as 
to destroy the vitality of this organ. The direct tendency of poison is to destroy 
the principle of life and inflammation is the means which nature employs to 
counteract the effects of the poison, and preserve the life of the parts. 

The inflammatory action, existing in the mucous membrane of the stomach, in 
those forms of disease called fevers, is the restorative power of nature in action. 
No person ever recovered from a low form of fever without some degree of in- 
flammation having existed in the stomach. In inflammation of the stomach, 
medicine should be given that will excite the secretions. Inflammation of the 
throat is relieved, and its efforts aided by gargling with tincture of capsicum, di- 
luted, which excites the secretions and relieves the congested vessels. It is as- 
certained that the mucous membrane of the stomach seldom exhibits marks of 
inflammation when patients die soon after an attack of some highly malignant 
form of disease, for instance yellow fever ; the force of the cause of the disease 
having suddenly prostrated the living principle so low that the constitution is 
unable to establish an inflammatory action. 

In pleurisy, inflammation of the lungs, rheumatism, erysipelas and other forms 
of disease attended with inflammation, conditions obtain which call for inflam- 
mation — the disease always existing before inflammation ensues. 

Thus.in pleurisy, the nutritive action being arrested, in a portion of the pleura, 
by debilitating influences, and its disorganization threatened, are conditions 
which call for a supply of arterial blood, and an inflammatory action, as the only 
means of effecting a restoration of the nutritive or assimilative action and sus- 
taining the organization. Not less salutary are the effects of inflammation, rheu- 
matism and erysipelas. 

Curative in design, the results of fever and inflammation are always benefi- 
cial under favorable conditions. Finally, whenever nature is called upon to re- 
pair an injury, or to protect an organ or tissue from disorganization, she per- 
forms the work by means of inflammation, aided sometimes by fever. 

It must be borne in mind, however, that the efforts of nature often require the 
aid of medicines and other means for regulating and sustaining her restorative ac- 
tions. In the case of a common boil, for instance, or in any other case of acute 
inflammation, there may be an undue accumulation of blood in the diseased 
parts, causing unnecessary pain and swelling and retarding the cure. 

[2] 



j g Principles and Practice of 

More especially are the resources of art demanded in the diseases attended 
with inflammation of internal organs, such as pleurisy, inflammation of the 
lunes dysentery, peritonitis, inflammation of the brain, etc. 

The principles of medicine may be deduced in part from a knowledge of ani- 
mal structure and function, (anatomy and physiology) conjoined with i an i ac- 
quaintance with the agents which cause and remove disease ; but chiefly they 
are derived from a generalization of facts observed in an extensive study of dis- 
ease itself, and its effects in the living and in the dead body. 

But so far as they have been ascertained, they become more intelligible to 
the student if explained synthetically, by describing first the causes of disease, 
then their operation on the body and lastly, the resulting changes in function or 
structure which constitute disease in its most elementaryforms. Etiology, or a 
knowledge of toe causes of disease, will introduce us to to their effect-^* 
itself; the nature and constitution of which will then be considered under their 
appropriate heads. 



American Medicine and Surgery. 19 



ETIOLOGY. 



THE CAUSES OF DISEASE— NATURE AND DIVISION OF CAUSES. 

Causes of disease are those circumstances which essentially precede it, and to 
the operation of which its occurrence is due. In many instances these circum- 
stances elude our observation; in many others the true cause, if apparent, is 
combined with other antecedent circumstances which have no share in produ- 
cing the disease, and yet are liable to be mistaken for causes. These circum- 
stances are to be sifted and the true cause discovered, only by the attentive ob- 
servation of large numbers of cases in which disease is produced. The non- 
essential circumstances #ill then be found to be sometimes absent, and that 
which is always present may be fairly regarded as the cause. 

But this, as before stated, sometimes eludes observation, and both in this 
case, and in elucidating the operation of circumstances supposed to act as 
causes, the most useful knowledge may be obtained from an investigation of the 
ultimate nature of disease itself which will often throw light on the cause which 
has induced it. 

Thus it was long a matter of doubt whether the itch could be engendered 
from filth, as well as from contagion ; but since microscopic investigation has 
discovered the existence of the itch mite, no doubt remains that this insect is the 
only essential cause of the disease. • 

The causes or circumstances inducing disease may be intrinsic, ox existing with- 
in the body independently of any obvious external influence, or they may be ex- 
trinsic, having their origin without the body. As examples of intrinsic causes 
may be mentioned excess or defect of some function, as irritability, or of some 
constitutent of the body as the blood. Extrinsic causes are very numerous, com- 
prising all the external agencies which can operate on the body or mind, such as 
temperature, air, moisture, food, poisons, mechanical and chemical influences, 
sensual impressions, etc., etc. 

A great variety of agents and circumstances may thus act on the body so as 
to produce disease ; but in most instances there is not that uniform and constan. 
relation between these as causes, and the disease as effects, which we might 
expect from the analogy of causation in the simpler sciences. In chemistry 
and in mechanics, effects certainly and uniformly follow causes ; in physiology 
and pathology, no doubt, effects also ensue; but whether these. effects shall be 
manifest as disease or not, will depend on many circumstances, of which we 
often cannot take cognizance. It is true that when the causes resemble an act 
like those of physics or chemistry, their proper effects will not fail to ensue. 



20 Principles and Practice of 

Thus a cutting instrument, a red-hot iron, or a corrosive liquid, will not fail 
to produce disease, because its operation is so energetic as to overcome all vital 
properties by physical and chemical force, and disorder must follow. Further, 
certain poisons and other potent agents, which act on without destroying the 
vital properties of living parts, may also, if of sufficient strength, pretty con- 
stantly produce morbid effects. 

Thus opium, taken internally, causes somnolency ; lobelia excites nausea and 
vomiting ; cantharides applied to the surface induces inflammation, etc. 

But the common causes of disease are seldom of this decided and positive 
character ; they are often present without disease ensuing, and they are known 
to be causes only because disease is observed to ensue in a greater number of 
cases when they are present than when they are absent. 

Thus, improper food is a cause of indigestion, and exposure to cold is a cause 
of catarrh ; yet many persons eat unwholesome food without suffering from in- 
digestion, and many are exposed to cold without "taking cold." But those 
who do suffer from indigestion observe that they do so more after taking im- 
proper food, and those who are affected with catarrh can often trace it to ex- 
posure to cold. 

The reason of this uncertainty of action is chiefly in various powers by which 
the body resists the morbific influence ; which powers vary much under different 
circumstances. The failure or irregular operation of this power constitutes one 
predisposition to disease. 

Causes of disease were formerly divided into remote and proximate; the 
remote include both the predisposing and exciting causes, the only circum- 
stances now considered as causes. They were called remote, not because they t 
are distant or not in the body, but because they are not, like the proximate 
cause, a constant and present part of the disease. The term proximate cause 
was used by Cullen, (after Gambius) to represent the pathological condition, or k 
essential bodily change, on which the symptoms depend ; and it was called a 
cause of the disease, because diseases were by him defined to be an assemblage 
of symptoms. 

But this essential bodily change is rather a part of the disease than a cause, • 
and must be considered under the head of pathology. 

Discarding, then, the term proximate cause, we have only to consider the 
predisposing and exciting causes. 

The co-operation of both these kinds of causes is generally necessary to 
produce disease. A number of persons are exposed to cold ; one gets a sore 
throat ; another, a pleurisy ; another a diarrhce i ; another some form of rheuma- 
tism ; and a fifth escapes without any disease. 

All five were exposed to the same cause ; yet it acted differently on all. The 
four first were predisposed to the disease which attacked them as soon as it 
was excited by the cold. The fifth had no predisposition ; the exciting cause 
was therefore powerless ; it was insufficient without the predisposing cause, .as 
in the other cases, the predisposition was insufficient until the exciting cause, 
the cold, was applied. 
.In some cases, however, where sufficiently strong, what is in a smaller degree 



America?t Medicine and Surgery. 21 

a predisposition, in a greater degree constitutes a sole cause of disease ; thus a 
person with a very weak stomach always has indigestion, whether an exciting 
cause be applied or not. 

So likewise exciting causes, if sufficiently strong, may produce disease without 
predisposition ; thus a person not predisposed to indigestion may be pretty sure 
to earn it if he take a sufficient quantity of fat, raw cucumbers, pickled salmon, 
or any other such indigestible matter. 

Take another example. A healthy person living in a marshy district may 
not get an ague until he becomes debilitated by any cause such as cold, or 
fatigue, then the poison will act. But without his being thus weakened, if the 
exciting cause be made stronger by his sleeping on the very marshy ground 
itself then the poison may act without predisposition, and the ague begins. 

The consideration of these facts throws some light on the nature of many 
predisposing causes. There is, in organized beings, a certain conservative 
power which opposes the operation of noxious agents, and labors to expel them 
when they are introduced. The existence of this power has long been recog- 
nized, and in former days it was impersonated. It was the archtzus of Van 
Helmont ; the anima of Stahl ; the vis medicatrix naturce of Cullen. But 
without supposing it to be aught distinct from the ordinary attributes of living 
matter, we see its' frequent operation in the common performance of excretion, 
in the careful manner in which the noxious products of the body, and offending 
substances in food, are ejected from the system ; in a flow of tears to wash a 
grain of dust from the eye ; in the act of sneezing and coughing to discharge 
irritating matters from the air passages ; and in the slower, more complicated, 
but not less obvious example of inflammation, effusion of lymph, and suppura- 
tion, by which a thorn or other extraneous object is removed from the flesh. 

This vis conservatrix is alive to the exciting causes of disease, and in per- 
sons of full health, it is generally competent to resist them. 

How it resists them will depend on what they are. For instance : Is cold 
the cause ? This throws the blood inwardly; which, by increasing the internal 
secretions, and exciting the heart to increased action, establishes a calorific pro- 
cess which removes the cold. Is the cause improper food ? The preserving 
power operates, by discharging this speedily, by vomiting or by stool. Is it a ma- 
larious or contagious poison ? It is carried off by an increase of some of the se- 
cretions. But if this resisting power be weakened, locally or generally, or if the 
exciting cause be too strong for it, then the cause acts and disease begins. 

In the cases hitherto noticed predisposing causes consist in absence or defi- 
ciency of power, rather than the existence of anything positive ; but sometimes 
predispositions depend on something positively wrong in function or structure, 
which alone may scarcely amount to disease, and this error may be congenital or 
hereditary or acquired from previous disease. 

It must be observed that predisposing causes operate chiefly through the con- 
stitution, or some of its powers ; hence they are often called constitutional 'or in- 
ternal causes, in contra-distinction to the exciting causes which are more com- 
monly external. 

But these terms are objectionable, because not always applicable. Some- 



22 Principles and Practice of 

times the term predisposing is also inappropriate, as in the following instance : 
Several persons are exposed to a malarious or infectious poison ; some of these 
afterwards suffer much from fatigue or privation ; they then begin to show the 
effects of the poison ; others who have not suffered this second trial escape un- 
hurt. The poison has entered the system of both ; the last resist its influence ; 
the subsequent weakening reduces the powers of resistance in the first-class 
and exposes ihe system to the exciting cause ; but occurring after, it cannot be 
said to predispose. 

Hence, under such circumstances, the fatigue or privation is called the deter- 
mining muse. The frequent inapplicability of the terms under which the 
causes of disease are classified, suggests the truth that these divisions of causes 
are rather conventional and convenient, than natural and philosophical. 

The true, simple view of causes, is that they are circumstances inducing dis- 
ease. If strong, one such may be sufficent ; and if weak, two, three, or more 
may be required to operate together, or in succession, before that change of 
function or structure which constitutes disease ensues. Which of these several 
circumstances respectively disposes, exists, or determines, and would therefore 
come under the divisions that I have endeavored to explain, will often be very 
difficult to decide. 

PREDISPOSING CAUSES OF DISEASE. 

Predisposing causes of disease commonly consist of various circumstances 
which influence the functions or structures of the body in an unfavorable man- 
ner.yet short of actual disease. It will be useful to illustrate them by examples, 
which I will group under the following heads : 

i. Debilitating Influence. 

2. Excitement. 

3. Previous Disease. 

4. Present Disease. 

5. Hereditary Constitution. 

6. Temperament. 

7. Age. 

8. Sex. 

9. Occupation. 

DEBILITATING CAUSES OF PREDISPOSITION 

Are the most numerous of any. So we might expect from the fact that consti- 
tutional generally implies power of resiiting disease. The weakness which 
renders the body liable to disease is that specially which enfeebles the heart, 
and impairs the tone of the arteries ; it is often accompanied with an unusual 
susceptibility of the nervous system which increases the liability of the body to 
suffer. 

IMPERFECT NOURISHMENT. 

From defect either in the quantity or quality of the food, or from incapacity 
of the digestive powers. 

This in itself may cause many diseases, particularly of digestion and nutri- 



American Medicine and Surgery. 23 

tion ; but it also weakens the power to resist cold, and produces a liabil.ty to 
low fevers and inflammations, epidemic and contagious disorders. Thus, the 
susceptibility of the body to cold, and to infection when fasting, is generally 
acknowledged ; and the rapid propagation of infectious diseases among an ill- 
fed population, such as the colored race, and laboring classes, is too well known. 

IMPURE AIR. 

The injurious effects of this are apparent in the pallid, cachectic complexion 
of the inhabitants of crowded cities, even those who live well and regularly. 
How do they contrast with the ruddy countenances of the hardy and coarsely 
fed mountaineers. So do they also in their liability to diseases, particularly to 
those of the organs of respiration, circulation and nutrition. 

One of the most fertile sources of infantile disease, is a w*ant of a due supply 
of pure and wholesome air ; the effects of which are sure to manifest themselves, 
though often obscurely, and at a remote period. It is physiologically impossible 
for human beings to grow up in a sound and healthy state of body and mind, in 
the midst of a close, ill-ventilated atmosphere. Those that are least able to 
resist its baneful influences are carried off by the diseases of infancy and child- 
hood ; and those whose native vigor of constitution enables them to struggle 
through these, become the victims, in later years, of diseases which cut short 
their term of life, or deprive them of a large portion of that enjoyment which 
health alone can bring. 

EXCESSIVE EXERTION OF BODY OR MIND. 

Exercise is beneficial to both body and mind ; but when in degree or continu- 
ance it exceeds what the strength can bear, or rest can recruit, the animal func- 
tions are exhausted, and lose their balance ; muscular tone is impaired, nervous 
excitability takes the place of strength, the circulation fails, congestions ensue, 
the blood is not properly purified, and the various organs are on the brink of 
disease. It is thus that the fatigued mind or body is peculiarly prone to suffer 
from causes of disease. 

Want of sleep has similar effects ; and when the body is extremely exhausted, 
even sleep, which is nature's best restorer, is disturbed by the imperfect per- 
formance of circulation and respiration in the excess of weakness, hence a 
liability to insomnia and nervous excitement from exhaustion. 

WANT OF EXERCISE, AND SEDENTARY HABITS GENERALLY, 

form another extreme which favors the production of disease. 

The healthy vigor of all the functions of the body and mind is best maintained 
by their equal and moderate exercise ; and the torpor of inactivity renders them 
incapable of resisting the causes of diseases. 

The muscular function, and with it the circulation of the blood, is the first to 
suffer ; hence first sluggish movements, and ultimately weakness of the heart 
and other muscles. The defective circulation is felt most at parts at a distance 
from the heart ; hence cold extremities, dry skin, congested liver, with its fre- 
quent concomitants, hemorrhoids, torpid bowels, and indigestion : whilst the 



24 Principles and Practice of 

heart itself and the organs near it may be oppressed and injured by the load of 
headache, vertigo, somnolency, dulness of the senses, etc. 

In nervous subjects, convulsive affections may be promoted by the same 
inequality of circulation. The respiration being little exercised, the task of de- 
carbonizing the blood is imperfectly performed, or falls more on the liver, hence 
the accumulation of fat in the textures, and the occurrence of bilious derange- 
ments. From this statement it is obvious that sedentary habits, where extreme, 
may be equivalent to produce disease, and where existing in less degree, they 
promote its occurrence from other causes, such as irregularities of diet, exposure 
to cold, violent exertion, etc. 

From such combination of influences arise various disorders of the digestive 
organs, heart, lungs, and brain, catarrh, gout, rheumatism, calculous affections 
diseases of the skin, etc. 

LONG CONTINUED HEAT. 

The debilitating effects of this agent are exemplified in warm climates and 
seasons. Under its influence the muscles, and with them the heart and arteries, 
lose power and tone, the textures become relaxed, perspiration is profuse, and 
internal organs, especially the liver, are too much stimulated by blood which 
has lost more than usual of its water and less of its hydro-carbon ; hence the 
disposition to bilious and liver complaints, dysentery and cholera. 

The action of l\eat is debilitating from the losses the economy sustains from 
the undue cutaneous secretions, and from the over-stimulation of the nervous 
system. This debilitating action of heat is increased when combined with 
moisture. 

Diseases of the gastro-intestinal mucous membranes are more especially de- 
veloped. Under the influence of these two agents combined — heat and mois- 
ture — there is a marked tendency in diseases to assume a typhoid or a dynamic 
form. 

Over-heated rooms and excessive clothing likewise predispose to disease by 
their weakening and relaxing influence. Warm clothing is a source of disease, 
and very often of the same diseases which originate in an exposure to cold. 
Over-heated sitting and sleeping apartments, warm, soft beds and bed clothing 
relax and weaken the frame, disposing to disorders of the renal, urinary and 
generative organs, and render the system generally much more impressible to 
external influences. A predisposition is thus induced, not only to catarrh, in- 
flammations, affections of the lungs and rheumatism, but to irregularities in 
the menstrual discharge. It has been remarked that the females of Holland, 
who generally use very warm clothing, warm apartments and warm beds and 
footstoves, are subject to excessive menstruation and leucorrhea. 

It may be remarked that most of the diseases of hot climates and seasons oc- 
cur rather at the termination of the heat than during its steady prevalance, and 
that therefore it predisposes to, rather than excites, the disease, which is the im- 
mediate effect of cold, or of irregularity of diet, or of malaria. 

Thus the bilious cholera of this country occurs chiefly in the early autumn 
when the cool of the evening forms a contrast with the heat of the day. The 



American Medicine and Surgery. 25 

chill suddenly arrests the perspiration, and throwing the blood inwardly, op- 
presses internal organs, especially the liver, whose vital energies have been ex- 
hausted by the influence of the previous heat ; hence coldness of the surface, 
and congestion of the liver and portal system, ending in flux, cholera, diarrhoea, 
dysentery, etc., 

LONG CONTINUED COLD. 

The experiments of Chossat and others clearly prove cold to be a direct sed- 
ative, capable of reducing all the vital properties. 

Cold applied suddenly and for a short time invigorates, because it is followed 
by a healthy reaction, in which the vital powers are exercised and exalted. But 
when long continued its own sedative and debilitating effects are permanent ; it 
weakens the circulation, especially that of the surface, causes internal conges- 
tions and directly lowers all the vital energies. Hence the most malignant 
forms of epidemic fever :n this country are observed to prevail towards the close 
of the very severe winters, and all diseases may then assume a typhoid type. 
This is observed chiefly among the lower orders, whose means do not enable 
them to protect themselves sufficiently against the inclemencies of the season. 
We have before adverted to the striking manner in which cold disposes the 
body to suffer from malaria. 

HABITUAL INTEMPERANCE WITH INTOXICATING LIQUORS. 

There is probably in this country no source of disease more fertile than this. 
Besides many which it excites it predisposes the body to attacks of fever, ery- 
sipelas, cholera, dropsy, rheumatic and urinary diseases, and if it do not increase 
the proneness to inflammatory disorders, the habit of intemperance certainly 
disposes them to unfavorable terminations, and causes many victims to sink af- 
ter accidents and operations which would be comparatively trifling in a sober 
subject. 

Nor can we wonder at the pernicious effects of this kind of excess when we 
consider the weakened state of function and structure which stimulating drinks 
induce, especially in the organs which they most directly effect — the stomach, 
the liver, the kidneys, the heart and the brain. We shall soon have to explain 
how such an unsound state of these organs peculiarly impairs the powers of 
the body to resist or throw off disease. 

DEPRESSING PASSIONS OF THE MIND, SUCH AS FEAR, GRIEF AND DESPON- 
DENCY. 

Many are the instances in which numbers, as well as individuals, have es- 
caped prevalent disease, until depressed by some unhappy event or apprehen- 
sion, and then they have fallen victims. Such was instanced in the ill-fated 
Walcheren expedition, and in many passages in the history of armies in pesti- 
lential countries. 

A defeat, a failure, or even bad news, made many succumb to the pestilence 
who had before escaped. 

It is a common remark that when a contagious or epidemic disease prevails 



26 Principles and Practice of 

those who take most precautions frequently suffer, because they are timid and 
fearful, whilst the stout-hearted and reckless are unscathed. When the mental 
energies are depressed by fear, grief, anxiety, disappointment, etc., the powers 
are less able to oppose the debilitating causes of disease, and individuals, singly 
or collectively, are, under such circumstances, especially liable to those disorders 
which are of a general or specific origin, as fevers, etc. There is nothing which 
more certainly predisposes the system to the operation of the exciting causes of 
fever than the fear of being attacked by it. 

On the contrary, when the mind is elevated by success, hope and confidence, 
or other exciting passions, depressing causes make little or no impression upon 
the constitution, and individuals thus circumstanced almost always escape from 
diseases which readily invade the fearful, the dejected and the disappointed. 

Indulgence of temper and passion not only predispose to disease, but fre- 
quently excite it, in the nervous, irritable and sanguine temperament. Diseases 
of the heart, brain, liver, stomach and bowels often originate in these sources. 
Uncontrolled passions of every description occasion a host of functional and 
structural disorders of the great vis :era, whilst moderation of all the appetites, an 
equable state of mind, and the moderate excitement accompanying a well-regu- 
lated application to business or study, are among the best means of resisting the 
impression of injurious agents. 

EXCESSIVE AND REPEATED EVACUATIONS, EITHER OF THE BLOOD OR OF 

SOME SECRETION. 

The weakening effect of a large loss of blood needs no explanation ; but the 
injurious infljeaoe of habitual losses or drains, if there be more thin the system 
can repair, is still greater ; for the functions then become depraved as well as 
depressed, a state of cachexia as well as ansemia is induced, and a little cause 
may suffice to determine many states of disease. 

Various hemorrhages, and discharges, menorrhagia, diarrhoea, leucorrhcea, 
and other fluxes, if in excess, reduce the powers of life and the capacity to 
resist disease. 

No secretion, however, weakens so much or so irreparably, when in excess, 
as that of semen. 

In many of the lower tribes of animals the males live till they copulate and 
then die, the reproduction of the species is at the expense of the individual. 

That our species is not wholly exempt from this law of organized nature is 
apparent from the fact that immoderate venery is known to produce extreme 
debility, and premature decay, and to dispose the body and mind to various 
diseases. 

Pulmonary and cardiac diseases, epilepsy, mania, and other disordered mani- 
festations of mind not unfrequently occur from the condition of the system 
induced by the abuse of this appetite. It also leads toother maladies by depress- 
ing the vital energies of the frame, and rendering it more assailable to the com- 
mon exciting causes of disease. 



American Medicine and Surgery. 27 

PREVIOUS DEBILITATING DISEASES. 

It is well-known that the body is unusually liable to disorder during con- 
valesence from serious maladies. It is weak in all its powers ; whilst the nervous 
system often obtaining the ascendency which is common in states of weakness, 
renders the body unusually susceptible ; and improper food, exertion, excite- 
ment, or exposure to cold, may readily produce the former or some new com- 
plaint. Hence convalesence from a severe disease is a condition of health tha't 
requires peculiar care. 

The functions are just resuming their balance, and have neither the vigor of 
action nor the power of resistance, which is the attribute of robust health. The 
diseases which leave the body most liable to derangement are those ending irr 
exhaustion, such as continued fevers and protracted and severe inflammations. 

Hitherto, we have considered only those circumstances which predispose to 
disease by their weakening influences. There are others of a somewhat oppo- 
site character which favor the production of disease by a state of excitement 
or activity. 

Thus, full living without an adequate amount of exercise, may bring the cir- 
culation and other functions up to a high pressure degree of activity without 
producing disease ; in fact, there is a redundancy of health, and there is more 
»■ than usual capability of resisting those causes of disease which operate by de- 
pression, such as cold, malaria, infection, etc. But there is a predisposition to 
suffer from causes of additional excitement ; thus irritants applied more readily 
induce inflammation ; violent exertion may cause hemorrhages, and in any organ 
the operation of a stimulus may heighten the actions to a pitch that is morbid. 
So, also, unusual vascular activity in a part, when insufficient to produce dis- 
ease, renders the part more liable to suffer from external causes. 

Thus the determination of blood to the uterus and mammas at certain periods 
renders them liable to disease at those times. Violent exertion makes the mus- 
cles or their fasciae peculiarly liable to rheumatic inflammation from the subse- 
quent action of cold and damp. Excessive indulgence in a stimulant, diuretic 
beverage, such as punch, renders the kidneys liable to inflammation, or conges- 
tion or exposure to cold. Inflammation or irritation of the intestines is not a 
common effect of cold, except when these viscera are under the exciting influ- 
ence of a purgative. 

The brain, if previously over-active from hard study, may be excited into in- 
flammation by alcoholic stimulus or strong moral emotion. 

Proclivity to disease is not unfrequently caused by previous disease, indepen- 
dently of the weakening influence before noticed. 

Th ; s is particularly the case with some inflammatory and nervous disorders. 
Thus, a child who has once had croup, is very liable to its recurrence. One at- 
tack of enteritis frequently predisposes to its recurrence. 

Convulsive disorders, such as cholera, hysteria and epilepsy are extremely apt 
to recur, and the longer they have existed, the more difficult are they to remove, 
and the more ready are they to reappear on the application of any existing cause. 

This is what may be called a habit of disease which is most important to pre- 



28 Principles and Practice of 

vent. There can be littie doubt that the previous attack in all such cases leaves 
some change of structure or function which constitutes the predisposition, al- 
though this change may elude our means of detection. Under this head we 
may mention constitutional predisposition to disease which are to be ascribed 
not to a previous attack, but to the persistence in the system of a cause of that 
attack. 

Rheumatism, gout, gravel, many cutaneous diseases, dropsy, jaundice, and 
many others, may be quoted as examples. A person who has once suffered 
from any of these is very liable to a recurrence on the application of an exciting 
cause, and this is because, although free from the first attack, he 
may not be free from some functional or structural imperfection which 
was the predisponent to that attack, and which may again «be brought 
into operation by the addition of an exciting cause. In most of these 
cases, the constitutional defect is in some of the processes of assimilation or ex- 
cretion, this defect being generally functual, but in some cases it is also attended 
with change of structure, especially in the great eliminating organs, the liver and 
kidneys. When the tendency to the diseases under notice is acquired, it may 
be often traced to causes which peculiarly affect these organs, such as intem- 
perance, irregularities of diet, sedentary habits and scarlet fever. Nor can we 
separate from this class of constitutional causes the predispositions to many 
structural diseases, such as the tuberculous and malignant formations. Where 
such have once appeared, there is a tendency to the production of more, al- 
though this tendency may be latent until brought into activity by an exciting 
cause. In the following pages many arguments will be found in favor of the 
view that the disposition to these diseases is connected with errors in the 
functions of assimilation and excretion. 

• 

DISEASE, ALREADY EXISTING IN THE BODY, 

Even when itself latent, often predisposes to other disorders, independently 
of its weakening effect. Thus tubercles and other tumors, structural lesions of 
the heart and other organs, otten induce irritations or obstructions of the blood 
vessels which, if not themselves causing open disease, render them ripe for dis- 
order from other causes. Tnus a person on the occasion of violent bjdily or vo- 
cal exertion is seized with profuse spitting of blood, which causes his death ; on 
opening the body many tubercles are found in the lungs, although there had 
been no obvious symptoms of their existence before the violent effort. 

Again, disease of the heart causing accumulation in the veins often leads to 
congestion of the lungs and liver, and it may on'y require the addition of an 
exciting cause, such as sudden exertion or an excess in diet to bring about an 
attack of asthma or jaundice. 

These are mere instances of causes coming into operation by accumulation. 
Granular disease of the kidneys, which impairs their excreting power renders 
the body more liable to suffer from infectious and other poisons, and from other 
exciting causes of disease. 

The predisposing causes hitherto considered may be called accidental or ac- 



American Medicine and Surgery. 29 

quired. There are others which are born with the individual, and others which 
arise from circumstances of age or growth. 

All these may be supposed to depend on something defective or ill-balanced 
in the organization which is insufficient to manifest itself until wrought upon by 
an external exciting cause. 

Of the predispositions born with the individual, the most generally acknowl- 
edged is hereditary tendency to disease. It is well known that scrofula, gout, 
rheumatism, epilepsy, mania, asthma, blindness and deafness, run in families. 

That this depends on individual peculiarities transmitted from parents to off- 
spring, appears from the fact that all children do not partake,or not alike, of the 
disposition. 

Thus it has been observed in constitutional syphilis, a first child born of pa- 
rents, one of whom has been infected, may be tainted with the venereal poison, 
whilst the second would be perfectly healthy, a third would be diseased, and a 
fourth sound, thus alternating as it were. Children born of gouty parents have 
escaped entirely the disease, but have transmitted it to their offspring, who have 
suffered from well-marked fits of podagra. Nay, sometimes a whole gener- 
ation is passed over, and the disease appears in a third. So, too, we see exter- 
nal organization, family likeness differently stamped on different children of the 
same family. The influence of hereditary transmission is proved by numerous 
and positive facts ; indeed, peculiarties of configuration or feature are not more 
decidedly transmitted from parents to the offspring than constitutional taint and 
certain pathological conditions. • 

It is not simply the influence of the temperament which, endowed with the 
same peculiarties, tends to produce the same disease, but a settled inherent dis- 
position to such or such pathological development which may be found, even 
when the resemblance does not exist. Under this influence the disorder may 
go on, being propagated from one generation to another, or it may stop at one. 

But in the latter instance it seems necessary that this influence should be ex- 
ercised in a regular, invariable and general manner, and in its expression great 
variety has been observed. Sex, in some families, would seem to modify the 
hereditary tendency, the females being attacked with one form of disease, and 
the males with another not analogous. This two-fold effect of hereditary effi- 
ciency in the same family would appear to be the result of a double influence, 
one disorder being derived from the mother, and the other from the father. In 
cases where the father and mother suffer under different constitutional disorders, 
a sort of crossing often seems to occur,— the disorder of the father attacking 
the girls, whilst that of the mother appears in the males. Generally the heredi- 
tary pathological tendencies of the mother are more readily transmissible than 
those of the father. 

It must not be supposed that hereditary proclivity to disease commences at 
birth. In a few instances it is congenital; but in the greater number it is devel- 
oped by growth or some other circumstances in life. 

Gout, for example.is acknowledged to be hereditary. A parent has it in middle 
or advanced life ; his son does not get it until about the same period, sooner or 



30 Principles and Practice of 

i 
latef, according to whether he lives freely or not. Here is something transmitted 
from father to son.yet not manifested in the son for forty or fifty years. It has been 
observed that diseases developed under the influence of hereditary predisposi- 
tion, generally manifest themselves at an earlier age than that at which the same 
affection is ordinarily developed independently of this predisposing cause. 

There are other instances, and very curious and interesting they are, in which 
the children of a family succumb to a disorder of which the parents have never 
exhibited any traces, When subsequently the father or mother, or both, are at- 
tacked, and thus the point of departure of the disorder which had exercised a 
sort of anticipatory action on the offspring is disclosed. This variety of hered- 
itary influence has been frequently observed, and especially with reference to 
insanity, in which disorder the children are not unfrequently attacked before the 
parent. 

A well authenticated instance of the same manifestation in tubercular disease 
is recorded by a late authority. A young man of 19 years of age, of fine con- 
stitution and great muscular development, after a violent physical exertion, 
was attacked with abundant haemoptysis, and shortly after well marked phthisis 
appeared and he soon died. Neither his father or mother had exhibited any 
tuberculous tendency, or a young sister, the only remaining child. 

When she reached nineteen years of age, the young sister was attacked with 
pulmonary tubercular disease, and succumbed; and it was not for two years 
subsequently that the mother, 53 years old, presented the first symptoms of 
consumption, of which she sofln died, thus exhibiting the existence of an heredi- 
tary influence whose effects had preceded the manifestation. 

Frequently, but not essentially, connected with hereditary conformation, is 
the peculiarity of constitution called temperament, which certainly predisposes 
to particular diseases, Temperament consists in a predominance or defect of 
some functions or set of functions. 

Thus the sanguine temperament implies an activity of the system which cir- 
culates red blood and a rich proportion of red particles, manifest in the excita- 
ble pulse and flushing cheek of those of this temperament, and further evinced 
in their quick movements and lively disposition. This temperament gives a 
disposition to inflammation, determination of the blood and active hemorrhage. 
The phlegmatic or lymphatic temperament is the reverse of the sanguine. It 
occurs in those with weak pulse and languid circulation, cold extremities and 
pallid skin. There is a deficiency of red blood and of vascular action and tone, 
and the proclivity is to watery fluxes, dropsy and other chronic affections. In 
the bilious or melancholic temperament, which is commonly met with in per- 
sons of dark complexion and gloomy disposition, there is probably a defective 
action in some of the bilary or digestive organs which are therefore more liable 
to derangement. 

The nervous temperament is externally manifest only by agitation or trepida- 
tion of manner. It seems to depend on the excess or want of proportion of 
some properties 6f the nervous system, and it predisposes to the disorders call- 
ed nervous— such as hysteria, nervous pains, spasms, etc. These tempera- 



American Medicine and Surgery. 31 

ments may be variously combined, The sanguine and bilious temperament 
are both subject to scrofula or tuberculous disease. The extreme sanguine and 
extreme bilious are more subject than those of either temperament not so de- 
cided. The word diathesis is often used to express a particularly morbid ten- 
dency, thus we hear of the inflammatory diathesis the scrofulous diathesis, etc. 
It is merely a term signifying disposition, without affording any clue to its true 
cause. 

The last head of predisposing causes to be noticed is age. The several changes 
in organization, as well as in external circumstance, which the animal frame un- 
dergoes at different periods of life, may naturally be expected to be attended with 
corresponding proclivities to disease. I proceed to enumerate a few of these, pre- 
mising that some of the examples may be entitled to rank under the head of ex- 
citing causes of disease, as well as under that of predispositions. 

IN EARLY INFANCY 

The low calorific power of the body disposes it to suffer from the bad effects 
of cold, whence the tendency to visceral inflammations. The skin is particularly 
liable to various eruptions in consequence of its tenderness and the new and 
drying medium in which it is placed. The redness of new-born children is ob- 
viously the result of the action of the air, it is often a vivid erythema, followed 
by desquamation of the cuticle and a yellow stain of the skin f^om extravasated 
hasmatosin, which is erroneously thought to be a kind of jaundice. Scrofu- 
lous, and other papular eruptions, often succeed, with impetigo of the face and 
eczema of the scalp ; tedema of new-born children is peculiar to this period of 
life. 

, The comparatively virgin state of the alimentary canal at birth renders it pe- 
culiarly susceptible of disorder, and a similar trial may occur at the period of 
weaning. Hence arise diarrhoga, vomiting, colic, waterbrash, atrophy and other 
ailments connected with disordered digestion, with that form of enteritic disease 
called cholera infantum, the great desolator of the infantile population of out 
Northern cities. 

The brain, excittd by the novelties of the external world, becomes rapidly 
developed, and in its increased activity and growth, is liable to various diseases, 
hence the proclivity to hydrocephalous convulsions, etc. 

The process of teething adds an irritaticn whrch, by its influence on the ner- 
vous system, the bowels and the air passages, disposes them to disorder. In 
early infancy, rachetism, with gangrene of the mou^h, {cancerum oris), the vari- 
ous forms of stomatitis and angina, as well as diptheritic inflammation of the 
larynx and trachea, are frequently met with. 

CHILDHOOD, OR THE AGE FROM INFANCY TO PUBERTY. 

The functions most active are those which administer to growth ; the organs 
of digestion and assimilation are therefore obnoxious to disorder, hence derange- 
ments of the stomach and bowels, worms, infantile remittent, etc. The activity 
of the nutritive function gives a preponderance to the fibrinous or protein con- 
stituents of the blood, and inflammations which may occur are often attended 



32 Principles ana Practice of 

with the effusion of much plastic or albuminous matter, hence the products of 
croup, tubercle, mesenteric disease, etc. 

The natural mobility (or activity of the excito-motory system) of childhood 
predisposes to chorea and kindred affections. At this epoch, too, tuberculous 
affection of the bronchial ganglia, mesentery, peritoneum, and cerebral menin- 
ges, are of frequent occurrence, and present some peculiarities in their course 
and character, as do also some of the acute inflammations of the pulmonary 
organs, as bronchitis, pneumonia, the latter generally occurring in the form 
called lobular. Stridulous, or crowing laryngitis, and hooping-cough, with the 
eruptive fevers, as scarlatina, measles, and variola and its modifications, are dis- 
eases of childhood. 

PUBERTY 

Brings with it many morbid susceptibilities, chiefly in the female sex, in which 
the important function of menstruation is to be established. Many and serious 
are the evils that are liable to be produced by external causes, which check the 
development of this function. So also when established, this function has its 
nervous as well as its vascular relations ; and where it is irregular or disordered, 
a predisposition is given to many maladies affecting the blood-vessels and their 
contents, the secreting organs and the nervous system. This is one of the most 
important periods of human existence, for during it the development of the 
organs of reproduction in the two sexes takes place, and the whole economy is 
brought into full perfection. The organs of respiration and of voice acquire 
their full growth and tone ; the muscles their due proportion ; and the cerebro- 
spinal system its complex and wonderful organization. The instinctive feelings 
and emotions reach their utmost limits ; and many of them, especially those 
relating to the sexual organs, acquire an ascendancy, and their indulgence be- 
comes a cause of disease. From this source frequently spring impotence and 
the extinction of families ; the infliction, during after life of many of the disor- 
ders which proceed from debility, and the exhaustion of the nourishment and 
vital energy of the various organs ; innumerable nervous and convulsive mala- 
dies, as hysteria, epilepsy, neuralgia, chorea, melancholia, mania, idiocy, etc., 
diseases of the heart, disorders of the digestive organs \ premature alopecia and 
old age ; the formation of tubercles and the production of pulmonary consump- 
tion, and lastly the transmission of weak and decrepid bodies and minds to the 
offspring, scrofula, rickets, marasmus, hydrocephalous, etc. The pathological 
tendencies of this age are especially characterized by exalted action. At the 
approach and commencement of puberty, the glandular system is extremely 
prone to congestions and inflammations, particularly the lymphatic ganglia of 
the neck and axilla. Tubercles are rapidly developed in the lungs, and these 
organs are much disposed to acute and chronic inflammations of their substance 
and mucous surfaces ; pulmonary hemorrhage replaces the epistaxies of child- 
hood, and in females dysmenorrhcea, protracted menstruation, amenorrhoea, leu- 
corrhoea, chlorosis and hysteria appear. 



American Medicine and Surgery. 33 

AT THE TERMINATION. OF GROWTH 

There is another critical period. The cessation of that appropriation of nourish- 
ment for the increase of the body that had hitherto been going on, may cause 
fullness of the vessels, and a disposition to hypertrophy, hemorrhage and inflam- 
mation in the more robust ; and in the cachectic, to morbid depositions, espe- 
cially of the tuberculous kind. The same redundancy of the vivifying fluid in 
active circulation, gives that buoyancy of animal spirits and impulsive energy of 
feeling and strength which are the characteristics of healthy youth ; yet this 
very exuberance of vital power, if not properly controlled and balanced, may 
constitute a tendency to disease, either directly, as where excitement rising 
beyond the limits of health borders on morbid action, or indirectly by leading 
to excessive exertion and subsequent exhaustion. 

Youth is the age of susceptibility to moral and physical impressions, and 
therefore of liability to the disorders which these are capable of producing. 

ADULT AGE 

Can hardly be said to predispose to any diseases, unless it be those arising out 
of mode of life. It is commonly a period of steadier health, because the func- 
tions are more evenly balanced ; but if the mode of life be unfavorable, bad 
habits are apt to become established, and by their continuance to induce disease. 
Thus gout, gravel, rheumatism, indigestion, and various other disorders are apt. 
to occur in middle life, because the predisposition to them is gradually engen- 
dered by some error in diet or regimen t-o slight to excite disease, but sufficient 
by accumulation to dispose to it, on the addition of an exciting cause. As the 
age of fifty is approached, the circulation becomes more languid, particularly 
that of the venous system ; hence the frequency of venous congestions and vis- 
ceral obstructions, with the numerous train of disorders they occasion, as hemorr- 
hoids, inflammations of the great cavities, affections of the heart, apoplexy, paral- 
ysis ; derangements of the stomach and bowels ; gout, rheumatism, diseases of 
the urinary organs ; hysteria, and uterine disorders ; hypochondriasis, and mental 
alienation. It is asserted that ataxis phenomena are more frequent accompani- 
ments of severe disease at this than at any other period. As age advances, such 
habits affect the organization, and accelerate those changes in the fabric by 
which our existence is limited to a span of years. 

It would occupy too much space to enter into the details of all these changes, 
but some of the principal may be briefly noticed, as illustrating the weakness 
and liabilities of advanced age. 

The changes which old age induces in the exterior of the body shows a failure 
of those functions which were active in youth. Instead of muscles, fat and in- 
teguments being nourished in the equal proportions that give beauty as well as 
strength to the form in mature life, the muscles become thin and sinewy ; fat 
becomes scanty, partial or in excess ; the integuments are loose and wrinkled,; 
or flat and flabby ; the joints stiffen, and the gait loses its firmness and upright- 
ness. These changes in the texture of the body are attended, and probably 
induced, by altered proportions in the different parts of the vascular system. 
3 



34 Principles and Practice of 

The pallid skin of age, contrasted with the ruddy blush of youth, proves the 
diminished development of the capillary blood-vessels, that great system which 
sustains the life and nutrition of the body; hence much of the blood that in 
earlier age circulated on the surface, giving vigor and sensibility to all the exter- 
nal organs, and life and susceptibility to all outward relations, is now accumu- 
lated in the interior, and confines its vivifying and nutrient influence more to the 
internal functions and structures, thus tending to render the individual more 
isolated and selfish. But the blood thus abounding in the larger vessels is not 
equally distributed within them. The diminished capillaries intercept some of 
the force by which the blood is propelled through the arteries ; hence this fluid 
stagnates and accumulates in the veins, which become distended and tortuous > 
whilst the arteries, exposed to the continued impulsive force from the heart, lose 
much of their elasticity, and become mere rigid tubes, causing the peculiar hard- 
ness of the senile pulse. The nutrition of the textures generally fails in activity, 
not in degree only, but in kind also, chemical transformations and deposits be- 
ginning to show themselves in the different structures. Thus fibrous and mus- 
cular tissues exhibit partial conversion into fatty matter, and osseous or petri- 
factive changes encroach on many structures of low organization, exhibiting a 
tendency to degradation to the composition of mere vegetable and mineral 
matter. 

This altered proportion of the blood-vessels brings with it morbid tendencies, 
the nature of which will depend much on the great moving power, the heart, 
now more than ever the prime agent in the circulation. 

If the heart be moderately strong, a fair balance may long be sustained, 
although hemorrhoids, varicose veins, and such irregularities from local obstruc- 
tions may occur. If the heart be too strong, which is often the case after a life 
of much muscular exertion, the small arteries may suffer from the unsoftened 
force of its pulses, particularly in the brain, and there is a liability to apoplexy 
or palsy ; and in mucous membranes there is a disposition to active fluxes ; 
hence catarrh, asthma, and affections of the urinary organs. 

The more vascular textures, especially of internal organs, are over-nourished, 
and increase in size or weight. If the heart be diseased or weak, there will be 
imperfect circulation and tendency to venous congestions, dropsical effusions, 
imperfect and disordered secretions, altered nutrition, and a general failure of 
all the functions which depend on a sufficient supply of arterial blood ; hence 
may arise diseases of the liver, stomach, kidneys, lungs, and in fact of any of 
the viscera; in extreme cases, the lower extremities actually die for want of 
circulation. 

If, instead of the organs of circulation, we were to take the alimentary, # the 
respiratory, or the urinary apparatus, we should here too find changes induced 
by age, which show the necessarily limited time that man's organization is in- 
tended to last. Old age is thus attended with increasing infirmities and liabili- 
ties to disease. The very strength and activity which some functions retain, 
may, from their partiality, endanger life ; and their gradual and more equal 
failure degrades the physical and often the mental frame of man to a lower 
scale of existence, until he sinks into second childhood, dotage, and imbecility. 



'American Medicine and Surgery . 35 

SEX. 

The liability which sex gives to the diseases of the respective generative 
organs, is too much of a truism to need mention. 

But the peculiarities of sex are not confined to these organs ; they extend to 
many of the structures and functions of the body. 

The male sex is remarkable for the higher development of the muscular and 
voluntary excito-motory system, with a corresponding strength of frame — for 
; !he stronger impulses of the animal passions, and for a greater endowment of 
the reasoning faculty. These respectively bring with them a liability to suffer 
•from diseases of the muscles, limbs, joints, heart and great vessels — from evils 
contingent on undue indulgence of passion or appetite ; and from "disorders of 
the brain and its intellectual functions. 

In the femate sex, the predominant bodily functions are the nutritive, the 
sensitive, and the involuntary excito-motory ; whilst the perceptive and instinc- 
tive faculties and moral emotions preponderate in the mind. Hence the greater 
■proneness of females to changes in flesh and blood ; to disordered sensation 
spasms, convulsive and other affections of the spinal system ; and to the direct 
-and indirect consequences of the indulgence, or thwarting of instinctive and 
moral feelings. 

The predisposing influences of the menstrual function have been before 
noticed ; it may now be added, that its cessation favors the development of vari- 
•ous diseases of function and structure, especially growths, simple and malignant. 

OCCUPATION 

Comprises many circumstances already noticed under the heads of predisposing 
•influences. Thus sedentary occupations include want of exercise, and some- 
times impure air; laborious employments operates as excessive exertion; other 
occupations may predispose to disease by the continued exposure to heat or 
-cold which they occasion. 

Some employments require constrained postures, which, if insufficient to induce, 
may yet promote the occurrence of disease ; thus engravers and watch-makers 
are liable to affections of the head from holding the head low ; shoemakers and 
tailors are subject to disorders of the stomach from their stooping forward at 
their work. 

In many other instances occupations induce disease rather by exposing the 
individuals to the exciting causes, than by inducing a predisposition ; but as be- 
fore remarked, the very circumstances which, in great intensity, suffice to ex- 
cite disease, in a lower degree may only induce a disposition to derangement. 
Thus the slow introduction of lead into the system occurring in the occupations 
of painting, plumbing, and enameling, card printing, may not cause colic until 
-cold or irregularity of diet becomes an additional or exciting cause. The same 
remark will apply to dry grinding, needle pointing, leather dressing and other 
unhealthy occupations. 

An important element in the influence which employments have in causing 
disease is the time during which they are pursued. Thus an occupation, not 
in itself unhealthy, may become so when continued too many hours in the day, 



36 Principles and Practice of 

and a work which is attended with risk may be often safely undertaken for 
short periods, with a due amount of relaxation or diversion to another pursuit. 

By attention to this point the injurious influences of occupations may be 
much lessened. 

EXCITING CAUSES OF DISEASE. 

We now pass to the consideration of the exciting or occasional causes of dis- 
ease, or those circumstances and agents, which, operating on the body, especial- 
ly when predisposed, may excite disease in it. It has been stated before that 
certain powerful agents, such as irritants or poisons, pretty surely cause disease, 
independently of constitution or predisposition, but, may much modify the char- 
acter of this disease in different cases ; and where the agents are less powerful, 
as in the case of common causes of disease, the effects will depend still more on 
the predisposition, and may be null where this is not strong. 

Exciting causes may be divided into cognizable and non-cognizable agents. 
The former class comprehend physical and mental agents of whose existence 
we can take cognizance, independently of their operation in producing disease. 
Thus cold we know by its effect on our instruments and sensations ; muscular 
exertion by our witnessing or performing it, and mental emotion by our con- 
sciousness of it. The non-cognizable causes, on the other hand, elude our sen- 
ses, and we infer their existence only from their morbific effects ; thus malaria, 
and infection we know by no other property than that in question. 

The following table includes both classes : 

Cognizable Agents^ 

1. Mechanical. 

2. Chemical. 

3. Ingesta. 

4. Bodily exertion. 

5. Mental emotion. 

6. Excessive evacuation. 

7. Suppressed or defective evacuation. 

8. Defective cleanliness, ventilation and drainage. 

9. Temperature and changes. . 

Non- cognizable Agents. 

1. Endemic. 

2. Epidemic. 

3. Infectious. 

COGNIZABLE AGENTS. 

Mechanical causes which injure structure, or impede or derange function 1 
Besides the obvious instances of tearing, cutting, pinching, striking and strain- 
ing,, which produce at once diseases which fall under the province of the sur- 
geon, the physician finds many mechanical causes of disease which he has to 
treat. Long continued pressure of articles of clothing may produce disease. 
Tight neckcloths may cause headache, or even apoplexy, by impeding the flow 
of blood from the head. Tight stays may caus 2 fainting by pressure on the. 



American Medicine and Surgery. 37 

"heart and great vessels, or colic and costiveness by obstructing the free pass- 
age through the great intestines. Pressure on the epigastrum by sitting at a 

• desk after a meal may x:ause indigestion 

Long continuance in one position, whether standing, sitting or lying will par- 
tially obstruct circulation and innervation, and produce swelling and paralysis 
of the lower parts, or of those beyond the seat of pressure, and in time may 

• cause inflammation and death of the parts pressed upon. Mechanical causes also 
operate within the body. 

A stone in the bladder irritates by its mechanical properties, especially if it be 
of an irregular shape, or it mechanically stops the flow of the urine, so also may 
a gall stone that of the bile. 

The intestinal canal is sometimes mechanically stopped by hardened feces, 
■and irritation and inflammation may ensue. The stomach is often irritated by 
the mechanical qua tities, bulk, hardness or asperities of its contents ; thence 
may ensue vomiting, indigestion or inflammation of the organ. The air pass- 
ages of needle pointers, stone masons,, etc., are irritated and inflamed, and at 
length altered in structure in consequence of the mechanical action of particles 
of stone or other substances, which these men are continually inhaling in the 
■ course of their employment. 

Such instances are endless, and the further effects of disease are also in great 
measure mechanical. For example, the influence of tumors, of diseases of the 
heart and vessels, the lungs and air passages, intestines and urinary apparatus, 
injuries and diseases of the bones and ligaments, etc., is in great part mechani- 

• cal, interfering with the natural mechanism. 

Besides their simple mechanical structures and functions, some mechanical 
injuries, when extensive, directly depress the vital powers; thus concussion of 
the brain, crushing or tearing off a limb, or a blow on the epigastrum causes 
: fainting and extreme weakness of the heart's action, and may thus cause death. 
Slighter mechanical injuries are causes of irritation or excitement, which may 
be local or general according to to the excitability and extent of the part irrita- 
ted. 

Che7iiical causes of disease are even more varied than mechanical, because 
chemical agents are more numerous. We are acquainted less with the chemis- 
try than with the mechanism of the animal body, and therefore can less distin- 
guish causes which act by chemical properties from those which have complex 
relations to vital properties. 

But we recognize chemical irritants in acids, alkalies and many salts, whether 
-applied to a part or inhaled in a gas or vapor. So what are called chemical pois- 

• ons, such as corrosive sublimate and other metallic salts, the strong acids and 
alkalies, iodine, chlorine, etc., produce disease by their known powerful chemi- 

- cal affinities, which tend to decompose tissues and disorder functions. We can- 
not doubt that many of the matters which cause disease in the alimentary canal 

'do so by virtue of their chemical qualities. The process of digestion, although 

.always in part chemical, is so under the superintendent influence of a superior 
vital power, no sooner does this power fail, or the chemical agencies or decorn- 

. positions become too strong for it," than we have fermentation and putrifactio'n, 



$8" Principles and Practice of 

which cause eructation of gas or sour liquid from the mouth. and there may follow 
the discharge of ill-colored and unusually fetid matter by stool ; then, too, may 
arise a number of disorders which may in great part be referred to the influence 
of these injurious chemical processes. 

There appear to be at least four modes in which chemical agents may excite 
disease in the body. 

ist. As local irritants, as the diluted acids, alkalies and various salts, chemi- 
cal operation of which is resisted by increased action excited in the part. The 
carious maxillarof the workmen exposed to -the vapors of phosphorus, would ap- 
pear to be due to this cause. 

2d. As corrosives, as in the case of strong acids, alkalies, some metallic salts,, 
chlorine and iodine which by their powerful chemical affinity, so completely over- 
come the vital affinities of textures as to decompose them, and thus to kill and' 
alter the condition cf the part. 

3d. As septics, promoting the spontaneous decomposition of' the fluids or sol- 
ids of the body in the same way that ferments or putrescent matters operate on> 
dead organic matter. 

4. As chemical alteratives, modifying the changes which take place in diges- 
tion, assimilation, transformation of textures, secretion, etc., as in counteracting^ 
acidity by alkalies, in variously influencing the state of the blood and urine by 
acids, alkalies, etc., and causing the production of hippuric acid in that excre- 
tion by the administration of benzoic acid.. 

The operation of chemical agents on the whole body will vary according to- 
their intensity and extent. 

Irritants, if extensively applied, cause feverish excitement. Corrosives, if act- 
ing widely, depress the vital power, like the shock of violent mechanical injuries;, 
if partially the vital powers are excited to resist them, and they operate as irri- 
tants. 

Septics, if very powerful, may speedily overwhelm the preserving vital pow- 
ers of the body, which then speedily passes into a state of corruption, as in the 
case of extensive gangrene, pestilential diseases, etc.; but if the septic matter 
be scanty, and the vital powers strong, they are excited to increased action, and>- 
by means of accelerated circulation and augmented excretions, the body may 
get rid o f . the offensive matter. Such struggles are instanced in typhoid fevers, 
epidemic cholera, dysentery, etc. 

The solid and liqitid ingesta are a fertile source of disease, and in various 
ways. Their mechanical and chemical properties have already been noticed, 
But, further, the ingesta may cause disease : 

ist. By non-alimentary matters acting injuriously. 
2d. By aliment defective, or ill-proportioned in quality. 
3rd. By aliment defective, or excessive in quantity. 

Of the non- alimentary matters contained in the ingesta, salt, spices, pickles, . 
and other condiments, and spirituous or fermented liquors, are frequent exciting 
causes of disease. 

They are all more or less irritating or stimulating to the digestive apparatus,, 
and if used indiscreetly, may induce inflammations, congestions and functionaL 



American Medicine and Surgery. 39 

disorders of these organs, and, in some instances, irritation of other parts and of 
the whole system. Salt in excess irritates the stomach, retards digestion, and 
causes feverishness with thirst. 

Many of these effects are due to the affinity of the salt for the water of the 
animal fluids, and may be induced by other saline matters besides common salt- 
Wherever excess of salt is contained in the body there will be exosmosis and en- 
dosmosis of the water from the adjoining vessels and tissues, until the salt is 
equally distributed among them, and before this is accomplished, there will be 
such a diminution of the fluids within the blood corpuscles, and on the surface of 
the membranes, as may readily account for the thirst and disturbance caused in 
the system. According to Liebig, sale impedes the deposition of fat. Animals 
will not fatten on salt food — a hint for the corpulent. But the operation of in- 
toxicating liquors is more extended ; being soon absorbed, their stimulant action 
is speedily exercised on different parts, especially on the vascular and nervous 
system. Being absorbed by the veins, they pass by the portal vein into the liver, 
the function and structure of which are particularly apt to suffer from excesses, 
especially when spirits have been freely indulged in. So, too, the kidneys, which 
are the natural emunctories through which such extraneous matters are elimi- 
nated from the system, are often over-stimulated, and are injured in their se- 
creting power, and ultimately in their structure also. The heart and vessels are 
over-excited at first, and afterward lose their tone ; and the processes of diges- 
tion and nutrition become impaired and modified. The nervous system is an 
especial subject of the disordering influence of intoxicating liquors. A large 
quantity taken at a time is a narcotic poison, inducing a short period of cere- 
bral excitement, or intoxication, followed by insensibility, in which the functions 
of the brain are more or less completely impaired, and in extreme cases those of 
the spinal marrow suffer ; and if the influence be insufficient to stop respiration, 
yet it may be imperfectly performed, and congestions are formed in the brain 
and other organs. Hence, apoplexy, palsy, phrenitis, or delirium tremens, may 
follow, and the whole frame may suffer from the effects -of the poison. Even 
when less excessive q-iantities are taken and their first effect is mere intoxica- 
tion, the headache, sickness, and loss of appetite, and the feelings of wretched- 
ness and depression which often ensue, sufficiently prove that disorder has been 
produced, and that such artificial excitements cannot be abused with impunity. 

The habitual indulgence in strong drinks causes further varieties of disease 
which are so prevalent as to deserve notice. When taken only or chiefly with 
food, not as a substitute for it, but as a constituent of general "free living" 
they contribute to the production of an abundance of ill-assimilated, over-heated 
blood ; which either finds its vent in eruptions on the surface, or in local hemor- 
rhages or fluxes, or causes various functional disorders, such as palpitation, 
vertigo, stupor, dyspepsia, bilious attacks, etc., or may tend to the production 
of a fit of gout or gravel. The latter results are promoted by such beverages 
as contain much free acid as well as an abundance of spirit, such as port wine, 
rum punch, and hard, strong beer. The less acid malt liquors, ale and porter, 
tend rather to induce liver disorders., and an abundant deposition of fat in the 
body. 



40 Principles and Practice of 

All these consequences will be much favored by sedentary habits and defi- 
cient excretions ; active exercise carries off much of the spirit and super- 
fluous aliment by an increased elimination of the acids of respiration and 
perspiration. 

The most disastrous consequences of intemperance are exhibited by the 
habitual drunkard, who, in proportion as he indulges in liquor, loses his appetite 
for food, and his power for digesting it. He then drinks and starves, and the 
disease which ensues comprises the exhaustion of inanition with the more di- 
rect effects of the alcoholic poison. Thus in delirium tremens, the drunkard's 
disease, together with the permanent restless excitement of the irritated nervous 
system, which adds more and more to the exhaustion, the weakness of the 
mind and body is fearful, and in bad cases effect even the organic functions, 
so that the pulse is very weak and frequent, the excretions scanty and depraved, 
and the respiration is too imperfectly performed by the involuntary powers to 
permit sleep to ensue. This exhaustion must soon terminate in death, unless 
prevented by appropriate treatment, and this must comprise besides lactuca, 
(the American remedy) capsicum and other stimulants to the circulation and 
respiration ; purgatives and diuretics to free the blood from the excrementitious 
matter that has accumulated in it, and flu<d nourishment to repair its waste. 

Without these adjuncts opium itself will not only fail to procure sleep, but 
its narcotic influence may extinguish the flame of life. 

The use of liquors, malt or spirituous, are uncalled for and their supposed 
advantages are more than counterbalanced by the evil effects on health that 
follow their long continued use, aside from the moral effect upon the ipdividual. 

Disease may be excited by unwholesome articles with which the food is adul- 
terated. To this class of causes belong various poisons ; the operations of 
some of these will be noticed under the head of "Modes of Death," (see chapter 
on Prognosis); but for further details, works on toxicology and materia medica 
must be consulted. There are some noxious matters occasionally mixed with 
food, which gradually produce deleterious effects. 

Thus salted provisions too long used will cause scurvy ; ergotted corn has 
been known to produce dry gangrene. Lead, gradually introduced, causes con- 
stipation, colic, paralysis, and atrophy. 

Impure water, used as a drink, is a common cause of disease, containing 
decaying vegetable or animal matter, it may induce sickness, diarrhoea, cholera 
and typhoid symptoms ; hard waters, which are impregnated with some of the 
salts of lime, render the bowels costive, and are supposed to favor the produc- 
tion of calculous diseases and bronchocele ; brackish waters, containing saline 
matter, may induce dyspepsia and diarrhoea ; chalybeates, containing iron, are 
constipating, etc. Under the head of non-alimentary ingesta, which may cause 
disease, we must reckon various so-called medicines ; and that not only when in- 
judiciously administered, but as commonly prescribed, the remedies considered 
necessary to cure or relieve many diseases are not uncommonly un?iecessary 
evils ; they remove one disorder by inducing another, and it is well if the evil 
thus induced is the least of the two. 

Aliment unfit in quality is another condition of the ingesta that may cause 



American Medicine and Surgery. 41 

disease. Man is, by nature and habit, an omnivorous animal, and in general 
his health is best maintained by mixed proportions and varieties of animal and 
vegetable food. The insalubrity of the simpler constituents of food, when 
separate, even those supposed to be most nutritive, has been well shown by the 
numerous experiments of Majendie, Gruelin and others. They fed dogs, geese, 
donkeys and other animals on articles which are generally considered highly 
nutritive, as sugar, gum, starch, oil or butter, the animals died with symptoms 
of starvation almost as soon as if they had been kept without food. Even bread, 
when too fine, is insufficient for nutriment. A dog fed on pure, white bread 
lived only fifty days, whereas another fed with the coarsest brown bread was 
well nourished, and seemed capable of living to an indefinite period. Accord- 
ing to the research of a commission of the French Institute, (the report of which 
was published in 1841) animals fed on pure fibrin, or albumen, or gelatine, die 
of starvation with reduced quantity and quality of the blood, almost as soon as 
if not fed at all. 

Gluten or vegetable albumen is the only simple principle which will alone 
maintain life, and the nutritious qualities of vegetable food depend chiefly on the 
quantity of this azotized principle which they contain. 

Bread may well therefore be called the staff of life. Even animal albumen and 
fibrin require mixture with vegetable matter to make them properly nutritious 
as well as wholesome, and gelatine and oily matters are still less available for 
nourishment without such combination. In the experiments just alluded to, an- 
imals could be supported on meat or flesh, which composes several of the ele- 
mentary matters, although they were not sustained by any one of these matters 
separately. The utility of a due combination of organic elements for the food 
of animals has long since been ably shown by Dr. Prout.who pointed to Nature's 
aliment, milk, as the great type of all proper kinds of nourishment, as it con- 
tains albumen, oil, sugar and water, so all other kinds of food used for ordinary 
sustenance, ought to include these elements, or others identical, that is, identical 
in ultimate composition with them, and it is quite true that all combinations of; 
food sanctioned by custom do comprise such ingredients. Bread contains two 
of these, gluten which is vegetable albumen, and starch which is identical with 
sugar, but bread is not relished without butter or some fat with it. Neither does 
meat, which contains albumen and fat suit the taste without a combination 
with bread, rice, potatoes or some vegetable which represents the amylaceous 
or saccharine principle. 

Much discussion has occurred of late as to the share or purpose which each 
of the elements of food serves in the animal economy, and to the extent to 
wh*ich they can be changed by the process of digestion and assimilation. Dumas 
and the French chemists generally have maintained that this process is limited 
to the separation and appropriation of principles ready formed in the food and 
does not extend to the conversion of one into another. 

Thus all the albumen or fibrin in the body is derived from the albumen or 
gluten of the food, and all the fat from fat or oil, contained in the nourishment. 
This view, as regards the formation of fat, is opposed by many familiar facts, 
such as the fattening of domestic animals with farinaceous and vegetable foods, 



42 Principles and Practice of 

which contain very little fat, and it has been completely negatived by the experi- 
ments of Petroz and Boussingault, which have prcved that geese and pigs du- 
ring the process of fattening, gain more fat than is contained in their food. It 
further appears probable that the conversion of sugar into fat is promoted by 
the agency of bile, for H. Meckel found that by keeping a mixture of bile and 
grape sugar at a warm temperature, the quantity of fat in the mixture increas- 
ed to double in five hours and more than treble in twenty-four hours. It is 
pretty certain, therefore, that fat may be formed from starch or the saccharine 
principle and probably from the albuminous also. 

But there is no decisive evidence to show that albumen or gelatine can be 
elaborated from fat, starch or sugar, at least under common circumstances, and 
it is certain that these elements alone will not long sustain animal strength or life. 

Baron Liebig has advanced a very comprehensive hypothesis with regard to 
the purposes of the different proximate elements of food. He considers that the 
albuminous principle alone supplies the material from which the textures and all 
the non-nitrogenous elements are converted into carbonic acid and water by the 
process of respiration for the production of animal heat. Although too exclu- 
sive to be fully admissible, the general outline of this view appears to be con- 
sistent with facts, and will assist us in studying variations in food as a cause of 
disease. The chief alimentary matters may be divided into the albuminous, 
the gelatinous, the oleaginous, and the saccharine or amylaceous, and we shall 
briefly consider how an excess or defect, and in some instances the quality of 
each of these, may operate in causing disease. 

Albuminotis or proteinaceous articles, such as the lean of meat, fowl and fish, 
gluten of bread and casein of milk, are those which supply the albumen and fi- 
brin of the blood and textures of the body. Hence defect of this kind of nour- 
ishment will cause, first, weakness of the heart and other muscles, and at length 
wasting of these and of other textures, with diminution of the quantity and 
richness of the blood. Excess of carneous food, particularly the richer kind — 
butcher's meat — tends to cause plethora, with an excited circulation and fever- 
ishness, which may result in hemorrhage, inflammation, gout, lithiasis, etc. 
Bad quality of albuminous food is peculiarly injurious to persons of weak di- 
gestive and assimilative powers. Thus the casein of cheese, the fibrin of stale 
or salted meats, and the gluten of sour or ill baked bread, or heavy pastry, in- 
stead of forming good protein, is apt to degenerate into the products of animal 
decay, lithic and lactic acids, urea, etc. Hence may arise gout, rheumatism 
calculous disorders, etc. In this statement I disregard the dogma of Liebig, 
that the ma*erials of food serve for respiration and nutrition only and that urea- 
lithic acid and excrementitious matters are derived from the decay of the tis- 
sues alone. 

Daily observation convinces the medical practitioner that in persons of weak 
assimilation certain articles of food, as specified above, so certainly and prompt- 
ly cause an increase of animal matter in the urine, that there can be no doubt 
that they are the direct sources of it. Gelatinous food, soups, broth, 
isinglass, jellies, etc., are by no means so supporting as albuminous matters, 
but when combined with bread they nourish the body so well that it seems very 



American Medicine and Surgery. 43 

probable that, in a healthy constitution, gelatine may assist in the formation of 
albumen ; but when used in excess, or to the exclusion of bread and meat, it 
ceases to be nutritious, and the strength and flesh will waste. 

Oleaginous or fat nutriment, butter, fat of meat, oils, and seeds containing; 
them, not only supplies the material for the adipose textures of the body, but it 
assists in the formation of other structures and secretions, (oil globules form- 
ing a normal constituent of them,) and it affords the strongest fuel for the 
maintenance of animal heat by respiration. From what has been before stated^ 
it may be inferred that fat may also be formed from saccharine and starchy 
food, as well as from the store-houses of the adipose membrane ; but defect of 
fat in the food has been observed to induce the following morbid results : loss 
of flesh, especially of the rounded plumpness and smoothness of surface, which 
becomes skinny, wrinkled, and often dry and scurfy ; deficient secretions of mu- 
cus at the orifices of mucous passages, and of synovia in the sheaths and 
joints ; insufficient formation of bile, and consequent imperfect digestion and 
feculent excretion, with diminution of animal heat. 

Excess of fat food may disorder the stomach by its indigestibility, becoming 
rancid and causing heart burn or sickness, and sometimes a bilious taste ; for 
much fat seems to induce a regurgitation of bile into the stomach, which is sup- 
posed to assist in its digestion (Beaumont) and absorption ( Matte ncci). The 
pancreatic juice is essential to the digestion, or appropriation and assimilation- 
of fat or oily substances, and with this secretion deficient, the fat or oily matter 
will be ejected from the stomach, or pass through the bowels without being di- 
gested or taken up. If the fat is carried into the blood, it may cause incon- 
venient obesity by its accumulation in the adipose texture of various parts of the 
body ; or, if the subject be naturally lean, and incapable of accumulating fat* 
the superfluity must be carried. off and the natural emunctories, the sebaceous 
follicles of the skin and the liver, may be disordered ; hence, acne and other fol- 
licular diseases of the skin, and various bilious disorders, will ensue. These re- 
sults will be more readily produced in sedentary persons, in whom the exercise 
©f the lungs is insufficient to consume the superfluous fat. On the contrary*- 
those who use active exercise can often take considerable quantities of fat with 
impunity, and sometimes with advantage. For similar reasons, oily food is bet- 
ter borne in cold than in hot climates and seasons ; thu?, as Liebig has pointed 
out, the Laplander relishes train oil, which serves to sustain the warmth of his 
body, whilst the Italian, in a sunny climate, prefers the less combustible food,, 
maccaroni and fruit, which nourish without heating. 

The quality of oily matter in the food is materially concerned in its morbific 
effects, those most prone to chemical change or to become solid, being more 
likely to disagree than others. Thus stale or tainted butter or fats, and rancid 
oils, are peculiarly offensive to the digestive organs, both from the production of 
injurious acids (butyric and oleic,) and from their compact globules rendering 
them incapable of the minute division necessary for their absorption and appro- 
priation to the nutritive process. On the other hand, fresh butter, mild fat and 
sweet salad oil, agree well and nourish, especially when intimately blended with 
farinaceous articles, although consisting of the same elements with saccharine? 



44 ■* Principles and Practice of 

matter, are not quite similar in their physiological effects. Like it, they proba- 
bly sustain the body rather by supplying a material for the process of respira- 
tion, than by nourishing the textures; they thus save them from the consuming 
influence of the oxygen absorbed through the lungs ; and if taken in excess they 
may either lead to the formation of fat, which is deposited in the textures, or 
passing into fermentation, they may give origin to ascetic, lactic and oxalic acids 
and other matters of an injurious tendency, and this latter effect oc;urs more 
from saccharine than from amylaceous food. On the alimentary canal, too, 
their effects in some degree differ, amylaceous food in excess impairing the ac- 
tion of the intestines, and the secretion of the liver, whereas sweet things often 
relax the bowels and cause a redundancy of bile. 

These different effects of saccharine matter are probably connected with its 
either often containing or readily forming vegetable acids which irritate the ali- 
mentary canal and which may become causes of dyspepsia, diarrhoea, diabetes, 
rheumatism, oxaluria, and other disorders of the same class. Amylaceous and 
other saccharine matters, forming the mildest materials of food, serve to dilute 
the stronger articles, fibrin and oil, and to render them both more palatable and 
more digestible, when, therefore, the former are deficient, the latter are more 
apt to disagree and fail to impart their nutrient properties. These and other 
vegetable principles, such as gum, vegetable jelly, extractive, etc., also contain 
alkali combined with vegetable acids which are decomposable in persons of 
strong digestion, and this alkali becomes useful in counteracting the acidity 
which results from the processes of transformation continually proceeding in 
the body. 

Thus fruits and other vegetables assist in neutralizing and eliminating lithic 
acid, and in preventing the occurrence of gout and gravel. 

This statement is in accordance with the views of Prout, Liebig and Wohler.; 
but I have restricted its application to the case of persons whose digestion is 
strong, for in those of feebler powers, I find commonly that vegetable acids 
and fruit increase the acidity of the urine, and are therefore injurious ; whether 
by passing unaltered through the circulation, or by irritating the primse viae, and 
thus leading to an unusual development of hydrochloric and other unchangea- 
ble acids, I cannot say, but the latter would appear most probable. 

Thus the selection and combination of articles proper for food would be a 
difficult task, requiring much scientific knowledge, and calculation, were it 
not that Nature has supplied us with an instructive guide, which happily adapts 
itself to the varied wants of the system in change of season and other circum- 
stances. The appetite and taste generally instruct us pretty safely as to the 
best proportions of different kinds of food ; but they must not be perverted and 
pampered by condiments and refined modes of cooking. These are expedi- 
ents to coax and deceive the appetite and taste, and if these guardians of the 
nutritive department are cheated, it is no wonder that the department becomes 
deranged. 

Aliment may be excessive or deficient in quantity. Sometimes the appetite 
is inordinate, more frequently it is pampered ; in either case, if gratified, more 
food is taken than the expenditure of the system requires. If the digestive or- 



American Medicine and Surgery. 45 

gans fail in appropriating the nourishment, they become distended, irritated 
and otherwise disordered by what they cannot digest. If they are strong, and 
digest the excess, they send too much chyle into the blood, over-distend the ves- 
sels, and derange the function of assimilation ; hence, may result plethora, ap- 
oplexy, gout, gravel or some congestive hemorrhage, or inflammatory disorder, 
to which the individual is predisposed. Such evil consequences of repletion will 
ensue the more readily in sedentary persons in whom the waste of the body is 
little, and the excretions scanty. Defective nourishment may excite various dis- 
orders. In the extreme case of privation of food, the cravings of hunger are 
alternated with nausea and a sense of sinking ; then follow extreme depression 
alternated with transient fever, delirium, and general disorder both of body and 
mind, with increasing feebleness and inability to maintain animal heat. It is a 
curious fact that, in this state, the stomach becomes inflamed, probably from 
the irritating action of its secretion on its unrelieved vessels. Even in less de- 
grees of abstinence enjoined in the treatment of disease, symptoms of vascular 
and nervous irritation often arise in the midst of general weakness. By many 
practitioners of the Broussaian school these symptoms are erroneously taken as 
indications of an increase of the antiphlogistic plan, when a judicious return 
to nourishing food will really prove the best cure. 

Deficiency of food, if long continued, causes general weakness of the func- 
tions, and wasting of all the textures except those of the nervous system. The 
blood becomes thin and easily extravasated, the gums spongy and bleeding ; fat 
disappears ; muscles become thin and flabby ; the legs osdematous ; diarrhoea 
often occurs, ulcers often appear in the cornea and other parts which are less 
vascular; a state of scurvy or cachexy is induced, from which, if advanced, an 
improved diet may fail to restore. 

Chossat found that, in animals gradually starved to death, the temperature 
progressively declined, and unless maintained artificially, the animals seemed to 
die of cold. All the textures, even that of the bones sustained great loss of 
weight, but those of the nervous centres far less than any other. 

This fact I would explain by the peculiar condition of the blood-vessels sup- 
plying these centres, which enables them to monopolize the little blood remain- 
ing ; and thus we gain a further interpretation of the predominance of nervous 
symptoms in persons suffering from inanition. In less extreme cases, poor liv- 
ing may excite scrofulous and tuberculous disease, and other kindred forms of 
degeneration of organs. The bad influence of poor living is much more felt in 
those who are confined in close habitations, as in prisons, poor-houses, the cabins 
of ships, and besieged towns, than in those who are at large ; and it is under 
such circumstances that the insalubrity of some kinds of food, however nutri- 
tious, becomes apparent. Thus, even bread with meat or broth will not preclude 
the occurrence of scurvy; but a sufficient addition of fresh vegetables, and even 
of potatoes, prevents this disease from appearing. The prolonged use of a 
scanty regimen is a frequent cause of obstinate constipation and various diges- 
tive troubles in those who fast through Lent. 

Excessive bodily exertion of various kinds is a common exciting cause of dis- 
ease. General muscular efforts, as in running, walking up hill, rowing, etc., 



46 Principles and Practice of 

hurry the movements of the blood back to the heart, and resist its distribution 
through the arteries 'in such a degree that the heart, lungs, brain, and other 
organs, have an unusual pressure of blood upon them. The heart, excited to 
inordinate action, is often strained and distended, and its function, or even its 
structure, and that of the great vessels, may be impaired in consequence. This . 
is especially apt to happen if there be already anything imperfect in the structure 
•of the organ, its valves or vessels; and there are naturally very various degrees 
of perfection and strength in these parts. The brain is particularly liable to 
suffer from violent exertion, especially if joined with a stooping or constrained 
posture ; for its vessels are not, like those of the limbs and trunk, supported by 
muscular pressure upon them, and the excited heart can therefore send its blood 
into them with more force. Hence giddiness, noise in the ears, deafness, defec- 
tive vision, convulsions, palsy, and apoplexy have been brought on by violent 
exertion. The lungs are also apt to suffer ; for the blood being returned to 
them farter than they can arterialize it, they become greatly congested, hence 
cough, dyspnoea, haemoptysis or inflammation of the lungs, may ensue ; and the 
texture of the lungs may also sustain injury in consequence of the violent strain 
to which it is subjected by the increased exertions for breath. Other internal 
organs are sometimes disordered by the blood thrown or retained in their ves- 
sels by the pressure of external muscular action. Derangement of the liver, 
haematimesis, haemorrhoids, and hematuria, have been brought on by such a 
cause. The sharp pains or stitches felt in the sides or abdomen, on running 
fast, are commonly supposed to be in the liver or spleen ; but more probably 
they are spasms of the intestines — temporary colic, produced by pressure on 
them, when their sensibility is raised by the blood unduly thrown into them. 

Some kinds of muscular exertion peculiarly affect certain organs. Thus 
loud reading or speaking, or blowing wind instruments, especially tries the 
organs of respiration, and the voice, and may cause haemorrhage, inflammation, 
and various diseases of these organs. Excessive or rough riding or leaping may 
injuriously affect the kidneys and organs of generation. Straining to lift a heavy 
weight, or at stool, or in any continued effort which implies holding the breath, 
endangers the structure of the vessels of the chest and brain, on which there is 
no equally counteracting muscular pressure. Bodily exertion, long continued, 
may also cause disease by its exhausting effects. In extreme degrees this ex- 
haustion may amonnt to syncope, and even death ; short of this it may cause 
great weakness of muscles and of the heart, with corresponding depression of 
other functions, with congestion of the viscera, defeef've assimilation and excre- 
tion ; hence arises low typhoid or adynamic fever, which sometimes follows 
prolonged fatigue. In slighter cases we have giddiness, faintness, nausea, loss 
of appetite, indigestion, costiveness, amenorrhcea, and other varieties of injured 
function. When exercise is carried on so long, or to such a degree as to impair 
the organic functions, it thereby induces disorders in them .in addition to the 
weakness, prostration, and actual suffering in the animal functions. A serious 
part of such disturbance is the sleeplessness which ensues from extreme fatigue, 
and which may bring the patient into a state resembling that of delirium tremens. 
This, as we have already mentioned under the head of predisposing causes, is 



American Medicine and Surgery. 47 

mainly due to the state of the respiration, which, being insufficiently maintained 
by the weakened spinal function, is aided by continued voluntary efforts, which 
are manifest in the frequent sighing that takes place. In this case, the best 
hypnotic will be found in a diffusable stimulant. 

The opposite extreme, want of exercise, is capable of exciting as well as of 
predisposing to disease. Thus, internal congestions, deficient and disordered 
secretions, general plethora, over nourishment of adipose texture, and wasting 
of muscles, and various consequences of these morbid conditions, may result 
from this cause when long in operation. When combined with some of the 
other disturbing influences noticed in this section, it is a still more ready and 
common cause of mischief. Some organs more particularly suffer from a seden- 
tary mode of life ; for example, the liver, from the increased task of decarbon- 
ization of the blood which deficient respiratory exercise throws on it ; the brain, 
from its vicinity to the centre of the circulation, exposing it to an accumulation 
of blood when the distant circulation fails ; hence bilious disorders, dyspepsia, 
haemorrhoids, headache, giddiness, etc. 

Strong mental emotion or acute sensation, is a common cause of disease. 
Closely knit together as the mind and body are, it is not surprising that they 
should ever be ready to affect each other, and that when the impression is 
strong, the affection should not be slight or transient. The heart most remark- 
ably suffers from such causes. Thus a sudden shock, whether of grief, surprise, 
fear, or even joy, may cause fainting, partial suspension of the action of the 
heart ; nay, even death has ensued, and the expressions "frightened to death," 
and "killed with joy," are not always mere figures of speech. Sudden acute 
pain often causes fainting. Palpitation and irregular action of the heart are 
very common effects of emotion. 

Other parts also suffer from strong moral impressions. Spasmodic asthma 
and spasmodic affections of the throat are sometimes thus induced. Apoplexy, 
palsy, inflammation of the brain, epilepsy, and insanity, have been caused by 
excessive anger, terror, surprise and joy. Very commonly mental emotions 
affect the secreting organs, and especially the functions of the alimentary canal. 
A piece of very bad news takes away appetite, or impairs digestion. Fright or 
anxiety often loosens the bowels, or brings on a bilious attack, or jaundice. 
The uterine periodic function is remakably subject to the influence of moral 
emotions, and many of its disorders may often be traced to this source. 

The slower emotions of the mind and over-exertion of its faculties are also 
exciting causes of disease. Long continued depression or anxiety sometimes 
induces dyspepsia, costiveness, or diarrhoea, asthma and functional disorders of 
the heart, menorrhagia and dysmenorrhcea, and in time structural diseases of 
the same parts, occasionally follow these functional affections. Over-exertion 
of the faculties, or excitement of the passions of the mind, are chiefly felt in its 
own functions, or in its own organ, the nervous system. Hence may arise 
congestions of the brain and exhaustion of nervous power, with giddiness, 
stupor, headache, dull and disordered sensation, and even apoplexy and palsy. 
Or the disease may be inflammatory, with symptoms of irregular excitement, 
nervousness, delirium, tremor, convulsion, partial paralysis, etc. Sometimes 



48 Principles and Practice of 

• 

the effects of excessive mental exertion or moral emotion are apparent only in 
the phenomena of the mind, the powers of which are injured or disordered, and 
various forms of insanity are produced. 

When we consider the variety and amount of food and condiment, employ- 
ment and excitement, that pass into the minds of persons in the busy and 
worrying scenes of civilized life, it is not extraordinary that the mind, as well as 
the digestion, or other function, should occasionally be disordered by such 
causes. 

Excessive evacuation or /^.either of blood or of some secretion was formerly 
noticed as a cause of debility which predisposes to other diseases, but if the 
loss be great or sudden it may produce immediate disease. A certain fullness 
of the heart and blood-vessels is required for their healthy functions, as well as 
for those of all the organs which they supply. If a moderate quantity of blood 
be suddenly withdrawn, or a large quantity less suddenly, the heart's action will 
be impaired, rendered irregular, and may be interrupted, and the brain not 
receiving a current sufficient to maintain its functions, there may be fainting, 
with loss of consciousness, accompanied or lollowed by disordered function, 
palpitation, delirium, convulsion, or by death. 

This being true, how fatal must have been the result of the old school plan of 
treatment, when Wood was drawn almost to depletion in the severest form of 
disease as well as the more trivial, from the already debilitated as readily as the 
strong and plethoric I The sudden impression in these cases is evidenced more 
on the brain than on the heart ; for these effects may be induced by the loss of a 
much smaller quantity of blood in an erect or sitting posture than in a hori- 
zontal posture. 

Similar results have been found to ensue from the sudden removal of pressure 
from the vessels in any considerable part of the body, as by the discharge of the 
fluid of ascites, or by enclosing a limb in an exhausting tube. Lower mentions 
a case of extensive enlargement of the veins of the lower extremities in which 
the patient could not stand without fainting, until the legs were bandaged. In 
these cases, much of the blood, although not removed from the system, gravi- 
tates into vessels, where it becomes unavailable for the general circulation. 
The fainting which occurs in these cases is called cerebral syncope because the 
functions of the brain are suspended, consciousness is lost before the heart's 
action is interrupted ; but the disorder of the brain reacts on the heart, and adds 
another influence to impair its action also. This is Dr. Alison's explanation. 

On the other hand, if the hemorrhage is gradual and the posture horizontal, 
other functions fail before the consciousness is lost — the chief symptoms being 
" feebleness of muscular action, paleness and collapse of the countenance, cold- 
ness, beginning at the extremities, cold sweat, beginning on the face, the pulse 
imperceptible," and the heart's action becoming so. The true nature of these 
effects, and the reaction and nervous symptoms with which they are often 
followed, will be considered hereafter in connection with the subject of anaemia. 
Not only blood letting but other evacuations, purging, sweating and vomiting, 
the catamenial and seminal. A man who, during his whole life, has exposed 
himself with impunity to the inclemencies of weather is attacked with rheuma- 



American Medicine and Surgery. 40 

• 

tism when exposed after excessive venereal indulgence. Under similar circum- 
stances the same disposition to attacks of yellow fever has been noticed in all 
epidemics of that disease. The depression and faintness induced by these, 
although less prompt, are often more permanent than those from blood letting ; 
for such evacuations imply not only reduction in the mass of blood, but also an 
exhaustion of the vital energies in the secretions and functions concerned in 
producing them. The diseases gradually induced by these several causes of 
evacuation are seldom of a simple kind. General weakness of the muscles 
and functions is commonly a result ; but this is often complicated by symptoms 
of a partial reaction, palpitation, spasms, noises in the head, images in the 
sight, pains in different parts, sometimes very acute, but seldom long fixed, 
I partial paralysis and a defective and disordered state of the secretions. 

Deficient evacuations of excrementitious matter, whether natural or acciden- 
tal, is a very fertile source of disease. The operation of this class is somewhat 
diversified, some causing disease by the positively noxious influence of the mat- 
ter retained in the system, which is the case of the urine and feces ; others, by 
causing fullness of the vessels, and the various disorders which his may induce. 
To the latter class belong sudden suppression of hemorrhages, or other dis- 
charges which have become habitual. 

The matter of alvine and renal excretions is essentially pernicious, and cannot 
be long retained even in their natural repositories, without causing mischief. 
Feculent matter, when it has reached the large intestine, is still acted on by the 
absorbents, which take up its more fluid parts, and with them, if long retained, 
fetid matter, which ought to be excreted. The solid residue becomes hard and 
scybalous; and may remain lodged in the cells of the colon, a cause of irrita- 
tion, distention and obstsruction. Sometimes the system suffers before the in- 
testine itself; at length, however, or sometimes at first, this part becomes irri- 
tated ; colic, diarrhoea and inflammation may ensue— nay, in some instances, 
where efficient remedies are neglected, even ulceration and other structural 
changes take place before offending matter is dislodged. 

The retention of urine has even more serious effects. Besides mechanical 
distention, irritation and rupture, which may follow from the constantly accu- 
mulating secretion, the fluid is partially reabsorbed, giving a urinous smell to 
the breath and perspiration, and sometimes causing typhoid symptoms, which 
in extreme cases prove fatal, with delirium, or convulsions and coma ; and effu- 
sions of serum, containing urea, are found in the brain, chest, and other parts. 
These are effects more commonly of suppression than of mere retention ; but, 
in fact, suppression follows retention : the retained urine is prone to decompo- 
sition ; highly irritating and offensive matters are produced, which cause injury 
to the bladder, rapidly extending up the ureters to the kidneys, whose function 
then becomes impaired or suppressed. 

In several cases of the early stage of the severest form of Bright's disease, 
in which the urine was very scantily secreted and highly albuminous, I have 
seen typhoid symptoms of the worst character ensue, accompanied by a break- 
ing up and partial solution of the coloring matter of the blood, with the appear- 
4 



ejo Principles and Practice of 

ance of pus globules in it ; in two instances there was effusion of a bloody pur- 
ulent effusion in the joints a day or two before death. These results will be fur- 
ther noticed under the head of defective excretion and purification of the blood 
as an element of disease. 

Checked perspiration is a well recognized cause of disease, commonly of a 
febrile or inflammatory nature ; but the sudden suppression of a foetid sweat 
in the feet, axillae, etc., has sometimes been followed by such serious disturb- 
ance of health as plainly indicates that the matter thus excreted is of a noxious 
quality. 

The preceding are extreme results ; but the attentive observer will find that 
smaller degrees of the same causes, insufficient secretion, or insufficient evacua- 
tion of excrementitious matters, are among the commonest sources of disorder 4 
and it is by a proper restoration of these functions that the almost universal do- 
mestic remedies, as well as the common pills and draughts of the surgery, prove 
so useful in preventing as well as in removing disease. We shall have many 
occasions to illustrate these facts. Numberless maladies arise from suppression, 
or irregularity of the catamenial discharge, which appears to be a highly car- 
bonized blood, and therefore its excretions give relief. 

Diseases are not unfrequently excited or rendered active at the period of its 
total cessation. The same may be said of the secretion of milk. The disor- 
ders which these first produce are commonly connected with local or general 
plethora, but eventually the quality of the blood in the body becomes altered 
as these excrementitious matters are suppressed. In artificial or diseased dis- 
charge or secretion, as that of a seton or issue, or from an ulcer or diseased 
membrane, or an unnaturally profuse flow of an ordinary secretion — such as 
looseness of the bowels, if so long established as to have become habitual — 
cannot be suddenly suppressed without great risk of exciting disease. In the 
case of habitual puriform or sanious discharges from setons, issues, and old 
sores, their sudden suppression has sometimes given rise to the most formid- 
able symptons, showing that a noxious matter had been thrown back upon the 
system ; and the fear of such accidental suppression which cannot always be 
prevented, deters me from frequently employing these artificial drains in the 
treatment of disease. The surgical treatment of fistula in ano is often fol- 
lowed by pulmonary consumption, hence my treatment of this class of diseases 
is always constitutional, and never merely surgical. 

Habitual hemorrhages, as from the nose or rectum, and the practice of peri- 
odical blood-letting, cannot be abruptly checked with safety. The maladies 
which result will vary with the predisposition ; but, generally, they are of the 
nature of local or general vascular fullness, or some disorders of secretion, or 
of the nervous system arising from disturbances in the circulation. As ex- 
amples may be named — congestion of the brain, apoplexy, congestion of the 
liver, various hemorrhages and inflammations, gout, epilepsy, palsy, hysteria, 
hypochondriasis, mania, etc. The suppression, or too rapid removal, of some 
cutaneous eruptions may be appended to this class. 

The diseases which it excites are sometimes inflammatory or profluvial, as 
gout, rheumatism, diarrhoea, etc.; sometimes more nervous, as chorea, epilepsy, 



American Medicine and Surgery. 51 

asthma, dyspepsia, hysteria, and in some cases tubercular consumption result 
as a sequel of the quick cures of some skin diseases. In removing all chronic 
ills, the system must first be prepared for the change. 

Defective cleanliness, ventilation and drainage. Much of the pernicious 
influence exercised by these causes might be referred to the last head, for there 
are few kinds of filth more offensive, few mephitic gases more foul, and few de- 
scriptions of offal more abominable than those that are excreted from the ani- 
mal body itself. And if, as we have seen, such matters' are so injurious when 
not sufficiently eliminated out of the body, it is not surprising that they con- 
tinue to be noxious, and may become causes of disease after they have been 
evacuated, if proper means be not taken to remove them. The necessity of 
^elf-purification is illustrated by the instinctive habits of many animals and 
•birds, which take much pains to cleanse themselves and tneir young and, in 
many instances, carefully remove excrements from their nests and habitations. 
Even plants are supposed, by some botanists, to exhibit a like provision for 
preservation against self-poisoning, in the constant spreading of their roots into 
new soil uncontaminated by their own excreted matter. Yet, with strange dis- 
regard of all instinctive feelings, and indolent neglect of the plainest dictates 
of reason, human beings are found continually exposing themselves to the influ- 
ence of their own accumulated filth, until disease is engendered and aggravated 
into pestilence, and the rate of mortality is doubled or tripled in the population. 

Although the three particulars, neglect of cleanliness, imperfect ventilation 
and defective drainage, operate much in the same ways, and are very com- 
monly combined, yet with a view to suggest a remedial means, it will be useful 
to consider briefly the modes in which each is known to excite disease. 

Filth accumulated on the surface, consists of the inspissated matter of per- 
spiration, together with any extraneous dust or dirt to which the individual may 
be exposed. 

The sweat is peculiarly rank and offensive in some persons, especially when 
accumulated during much muscular exertion, and in some parts as the axillae 
and perinasum, and between the toes, is combined with an odorous principle, 
the disgusting character of which seems to be intended by nature to suggest the 
necessity of frequent ablutions. Yet how many, and these not confined to the 
lower ranks, are "content to live in dirt and stink," and often eventually to pay 
the penalty of their filthiness in various cutaneous diseases which are thereby 
induced. In young children, in females, and in many aged persons, the urine 
dispersed in the vicinity of the secreting orifice becomes an additional cause of 
irritation and offense. The accumulation of filth on the surface further favors 
the propagation of vermin and of contagious diseases, especially the itch, from 
which few of the "mighty unwashed " are totally free. It also impedes free 
perspiration, and thus favors the production of rheumatism and diseases of the 
urinary organs, and others which sympathize with the skin. Neglect of clean- 
liness in clothes and dwellings, if not equally injurious by direct contact with 
the body, becomes hurtful by contaminating the air. Mortality is invariably 
commensurate with the filth and destitution of the inhabitants, and the impu- 
rity of their abodes. 



52 Principles and Practice of 

Defective Ventilation, or insufficient change of the air of dwellings, might 
be considered to readily suggest its proper remedy by the feeling of suffocation 
induced; but it is not such a deficiency of oxygen, or excess of carbonic acid' 
as induces a stifling sensation that does most harm, it is rather the scanty supply 
of fresh air that stints the vital processes without suddenly disturbing them, and 
the gradual accumulation of foul effluvia that slowly poisons, without exciting 
alarm. Persons are gradually brought to endure without complaint the impure 
air of a close room, which to any one entering it from the open atmospheres- 
seems quite suffocating. 

Thus, in the habitations of the poor, especially in densely populated towns, 
it is not rare to find ten or fifteen crowded together in one small room, without 
any other supply of air than that which comes through chinks of the floor of 
window, or when the door is accidentally open. Among this class the dread of 
cold prevails much more than the desire for fresh air, and except in the height 
of summer, the solitary window may be rarely opened ; and during the night 
when the greatest number are collected together, every opening is kept carefully 
closed. During the winter the same plan is pursued, but then, if there be any 
fire in the hearth, it will ensure a greater amount of ventilation. 

The habitual want of pure air especially exercises an unfavorable influence 
on the state of the bloody and the functions or circulation and nutrition, causing 
pallidity of the surface, poorness of the blood, imperfect development of the 
fibrous principle, which, instead of contributing to the nourishment of the mus- 
cles, degenerates into scrofulous or tuberculous matter, the deposition of which 
in the internal organs or glands is favored by the weakness of the circulation. 
Exercise may in some degree counteract this effect of impure air. Thus Dr. 
Guy found that in the close workshops of a printing establishment, the compos- 
itors whose work requires no exertion, fall victims to phthisis, in the proportion 
of 44 to 31 1-2 per cent of the pressmen, who, while breathing the same air,, 
use active bodily efforts. This difference is quite intelligible when it is remem- 
bered that active exercise, by increasing and extending the force of the circula- 
tion, tends to remove congestions, to promote excretion, and by the activity of 
the respiratory function enlivens and purifies ihe condition of the blood. Sim- 
ilar exercise in pure air would have much more salutary effects, the deaths from 
the same cause in out-door laborers not exceeding 25 per cent. Insufficient 
ventilation is by no means confined to the dwellings of the poor. In modem 
days, when workmanship of houses is more complete than it was in olden times, 
there are no longer latticed^ casements, chinky floors, ill-fitted doors, and above 
all the roaring pile in the spacious hearth, that supplied abundant ventilation to 
the houses of our forefathers; now, in proportion as houses are "well-built," 
every crevice is so thoroughly stopped that our rooms, when closed, are well 
nigh air-tight, and their'occupiers are enclosed in an atmosphere which is dete- 
riorating in proportion to the number assembled. Add to this the vitiating effect 
of artificial lights, and of fires, the smoke of which may not freely escape for 
want of a due supply of air, and it will appear how modern houses often com- 
prise the conditions calculated to produce this cause of disease. In public offi- 
ces, schools, hospitals, churches, chapels, theatres, and other places where great 



American Medicine and Surgery. 53 

numbers are collected together the cause is still more fully in operation, and it 
is quite certain that not only is the public health much injured thereby, but much 
of the useful or agreeable objects of such assemblies is defeated through the 
discomfort produced by the closeness and foulness of the air. The ill effects of 
deficient ventilation are increased by heat and moisture ; the former operating 
not only by increasing the animal exhalations but also by rarifying the air, and 
thus reducing the amount of oxygen in a given bulk; moisture probably acts in 
a degree in like manner, but also, as I conceive, by removing the difference be- 
tween the air respired and that in the lungs, which promotes that diffusion or 
interpenetration of gases on which the access of oxygen to the vesicular struc- 
mre of the lungs depends. For be it remembered, the air taken in at each in- 
spiration, is not enough to reach far in the tubes ; its transfer into the air cells is 
accomplished by the law of diffusion of gases, which operates in proportion to 
the dissimilarity between the gases, and difference in amount of contained wa- 
tery vapor must exemplify this law. 

In certain occupations, gases or vapors of a postitively noxious quality are en- 
gendered, and augment the evils of deficient ventilation. Such is the case in 
many chemical works, slaughter-houses, and dissecting rooms, soap, glue and 
catgut manufactories, and in the employment in which materials are used con- 
taining mercury, white lead and arsenic. The deleterious operation of effluvia 
arising under these circumstances, may be short of a directly poisonous effect, 
yet, by adding to the unwholesomeness of the atmosphere, it gradually under- 
mines the health, and is best to be counteracted by a more efficiesi^means of 
ventilation. ^Ms 

Defective drainage, comprises much of the influences exercised by the pre- 
ceding causes, filth and foul air; but it includes also circumstances that may 
exceed them in pernicious operation. The soil which drains from habitations, 
contains, in addition to excrement, dirty water, washings and remnants of ani- 
mal and vegetable matters used as food, and other offal ; and all these, when 
mixed and stagnant, constitute the corrupting slough retained in the cess-pools 
and privies, and carried into sewers. The stench which these exhale, when 
opened, gives some idea of their deleterious influence ; and the fearfully poison- 
ous nature of the gases which they emit has been proved by the sudden faintness 
and sickness, nausea, vomiting and diarrhoea, which have attacked persons en- 
gaged in emptying them. Instances have occurred of individuals being speedily 
asphyxiated by the gases of cess-pools ; and where the result is not immediately 
fatal, a congestive or typhoid pneumonia ensued which passed into gangrene in 
the first stage. The precise nature of the gases evolved is not fully ascertained, 
but they obviously contain much sulphureted and carbureted hydrogen, which 
although known to be highly noxious, probably do not comprise the most dele- 
terious part of these offensive effluvia. It is no wonder, then, that every ill- 
drained house should have a Pandora's box, ready to pour forth its evils when- 
ever occasion offers, and always oozing them out in degrees sufficient to impair 
the health of the inhabitants and gradually to excite cachectic and other chronic 
diseases. 

Hence, as it appears in all sanitary reports of all large cities supplied with 



54 Principles and Practice of 

sewerage, the mortality rises in a remarkable proportion in all those districts of 
towns where sewerage is absent or inefficient. The worst nuisance of this des- 
cription is the cess-pool without a drain from it, unemptied for months or years,, 
and often imperfectly covered, it continually poisons both air and water, and 
typhoid fever, diarrhoea, cholera, dysentery, dyspepsia, inappetency and general 
weakness and mal- nutrition are results of different degrees of its pestiferous 
operation. Scarcely less injurious and more insidious in its operation, because 
the effluvium is less offensive, is the untrapped drain in connection with the 
sewers of large towns. This cause of disease exists extensively, not only in the 
street drains which are always open and emitting the gases of the sewer, the 
bad odor of which is perceptible in certain winds, but also in the drains of$ 
houses which are either intentionally or negligently left open, or are not air-tight 
from the absence of water in the traps. 

Nothing is more common than to perce ive the peculiar smell of the drain on 
entering a house, and in many instances I have found that this has proceeded 
from the trap left open, or dried up, and therefore inoperative, and requiring 
only the simplest expedient to stop the evil. When a single trap is open in a 
house, especially in the winter when doors and windows are closed, and there is 
no adequate supply of air for the fires in the house, the foul air is drawn up 
from the sewer in a strong currrent from bottom to top, carrying with it a 
pernicious influence. 

It is suprising how ignorant servants and employers, and even professional 
men, are on this point, which so immediately concerns their health and comfort; 
and I have visited in many houses where this has seemed to be a cause of 
illness or impeded convalescence, in low nervous fevers, bowel complaints, 
influenza, neuralgia, headaches, and other similar ailments. In some instances 
the leakage may be in consequence of the inroads of rats, or in the displace- 
ments of the brickwork of the drains. It may be useful to state that, besides 
by the smell, which is not obvious to every one, the effluvia of drains may be 
detected by the darkening of white paint, and the early spoiling of meat in the 
lower basement story of the house. 

Of all the exciting causes of disease, there is none so common as temperature 
in extremes, or in sudden transitions from cold to hot, or hot to cold. Both 
heat and cold have different modes of operation, and cause disease in different 
ways. 

Extreme heat and extreme cold are directly destructive to life. Heat above 
1 80 degrees coagulates the albumen of the blood, and thus obstructs the blood- 
vessels, and may cause other chemical changes of a disorganizing nature ; a 
part that has been raised to this temperature, therefore necessarily dies ; it can- 
not live again. It is true that we occasionally see boiling water at 212 degrees, 
boiling oil at 600 degrees, and red hot iron at 1,000 degrees, produce no other 
effect than inflammation and blistering of a part, but that is because these 
bodies have been applied too short a time to do more than violently stimulate 
the part, not time enough to raise it to the decomposing temperature; a few 
seconds more and the part would be killed. Cold below 32 degrees freezes the 
water of the fluids ; and as it destroys the life of tender plants, so it kills parts- 



American Medicine and Surgery. 55 

of animals, whether by the expansion of the ice injuring the delicate organiza- 
tion, or whether from the mere stoppage of the circulation, or other cause, is 
unknown. The part may be afterwards separated from the living parts by a 
vital process of inflammation and sloughing. A disorganizing degree of heat, 
extensively applied, acts like a violent mechanical injury — such as tearing off or 
crushing a limb. It directly depresses all the functions; the pulse becomes 
very weak, frequent and sometimes irregular; the muscular strength almost 
annihilated, and consciousness may be nearly or quite suspended. In this 
state, notwithstanding the stimulant properties of heat, and the inflammation 
which it generally excites, patients require stimulants, and they often die in a 
state of complete collapse, without any rallying or reaction. Extreme cold, 
also, if for sometime applied to the whole body, depresses and paralyzes all its 
powers, even that of generating heat, and threrefore of resisting cold. 

Sir Astley Cooper observed, that on plunging kittens into ice cold water, the 
arterial blood did not become venous in the veins ; and Chossat found, in 
animals killed by cold, arterial blood in the left cavities of the heart. From a 
similar cause, the limbs became benumbed by extreme or continued cold ; thus 
persons are drowned m cold weather much more speedily than in warm. 

With less intense degrees of cold, on the other hand, which do not destroy 
the vital processes, more oxygen is absorbed, more carbonic acid formed and 
heat generated, which are the meaus by which animals resist cold. Heat, which 
is insufficient to decompose, is directly stimulant. It excites the function of 
parts, and when generally applied induces a state of fever. Thus when a person 
is in a vapor bath, or hot air bath, the pulse quickens, the whole surface 
becomes red, full and hot ; there may be throbbing and pain in the temples, and 
a feeling of feverish oppression, until a sweat breaks out, which relieves the 
superficial tension and fullness and soon reduces the increased heat. 

Similar results may ensue from confinement in overheated rooms, and if there 
be any tendency to local congestion or inflammation, particularly in the head, 
this excitement may be enough to produce it. The continuance of heat 
enervates, reduces the strength and appetite, and may excite a feverish state, 
with disorders of the liver. The oppressed breathing which is often felt in 
heated rooms may according to the view of Liebig, be"ascribed to the smaller 
amount of oxygen in the air rarified by the heat ; but it is probable that this is 
not the only cause. A. mere partial exposure of the body to heat may pro- 
duce still more disordering effects, if the part over-heated be capable of suffer- 
ing from the excitement. Thus solar or artificial heat to the head may cause 
severe headache, apoplexy, or inflammation of the brain. Heat to the spine, as 
on sitting with the back near a large fire, is very apt to cause sickness and faint- 
ness, and, if continued, may induce convulsions. 

Mere loeal inflammations, as of the eye, ear and skin, are frequently caused 
by exposure of the parts to heat. Gout may sometimes be excited in the feet 
by the same stimulus, and this is often attempted purposely. 

Cold, on the other hand, is directly sedative. It contracts tissues and vessels, 
especially on the arteries, and thus at first renders parts pale and shrunk. In 
persons of feeble circulation, after bathing, the fingers are sometimes quite 



56 Principles and Practice of 

bloodless and numb from this cause, the cold having quite closed up the 
arteries. But cold also retards the passage of the blood in the capillaries ; the 
viscidity ot the liquor sanguines seems to be increased ; globules stick to the 
sides or move but slowly, and the part soon becomes purple or blue from the 
congestion of the blood in it. This purple color is chiefly seen in parts much 
exposed, and where the blood habitually enters with freedom, as the cheeks, 
ears, nose and hands. There is also much external congestion from the intro- 
pulsive operation of the cold — that is, the external parts being constricted and 
obstructed, blood accumulates more in internal parts, and the heart's force is 
more expended on these. This may, in part, account for the degree of stupor 
and ultimate insensibility into which persons exposed to extreme cold are apt to 
fall. In some such cases there has been a flow of blood from the nostrils or 
ears; the stupor has continued for hours after the heat and circulation have been 
restored, and, in fatal cases, much serous effusion has been found in the brain. 

Hitherto we have considered the immediate operation of cold. But its 
indirect effects .are most commonly known; these are reaction, in itation and 
their consequences, and they will be more manifest when the cold has been 
partial and the strength of the circulation generally not reduced. Thus after a 
part has been exposed to severe cold, when restored to warmth, it becomes the 
seat of increased flow of blood, which causes redness, pain and more heat, and 
various forms of inflammation may ensue, generally modified by the specific 
effect which the cold has exercised on the vessels and nerves ; varying also 
with the strength of the general circulation. Thus, as the indirect effects of 
cold in a part, we may have chilblains, gangrenous or erysipelatous inflamma- 
tion, and paralysis or altered sensation. As much of the disease in these partial 
effects of cold arises from the violence of the reaction and inflammation, and 
this depends on the sudden return of heat and circulation in the part, it becomes 
an obvious indication, for frost-bitten limbs, to retard this return by cold appli- 
cations. But Dr. Allison well remarks that this precaution is not needed 
where the sedative effects of cold have been more general ; here warmth and 
stimulants may be used freely, for there is no fear of partial injurious reaction. 
We have hitherto chiefly considered the manner in which cold causes disorder in 
the parts to which it is applied ; but this is not the most common mode in 
which cold excites disease. 

A person gets his feet wet, stands in a draught of cold air, or is exposed to 
cold when insufficiently clothed ; he afterwards becomes diseased — not in the 
feet or the parts chilled, but in some internal part. He gets a sore throat, or a 
" cold in the head," or chest, an inflammation of the lungs, a rheumatism in the 
limbs, a looseness of the bowels, a catarrh of the bladder, or any other disease 
to which he may be predisposed. Now, how does the external cold cause 
internal disease ? How is the effect transferred from external to internal parts ? 
Dr. Allison supposes that the cold operates chiefly on the nerves, and that the 
sensation which it excites is conveyed also by the nerves to the internal organs, 
where its morbid effects become manifest. 

But it must be objected that the morbific effects of cold are by no means 
proportioned to the sensation or known nervous impression, which it excites. 



American Medicine and Surgery. 57 

A person may have his limbs aching and benumbed with general cold ; yet 
internal disease does not result. But if he has been exerting himself, is perspir- 
ing, and then gets his feet wet, or is otherwise exposed to cold, especially partial 
without continuing his exercise, although he may scarcely feel the cold, yet he 
will be pretty sure to catch cold and to exhibit some one or other of its internal 
morbid effects. It would seem more probable, therefore, that external cold 
excites internal disease by deranging the circulation, particularly that in the 
capillaries. 'Cold checks the external secretion, the perspiration ; it constricts 
and obstructs the vessels of the surface and must thus throw more blood 
inwardly, so that internal congestions are produced — these internal congestions 
impair the functions of the affected organs, especially those concerned in excre- 
tion and in other ways lay the foundation of disease. This intropulsive effect 
of cold will take place more readily and to a greater extent, in proportion to the 
weakness or sluggishness of the capillary circulation. This may be weak 
naturally ; in this case there is a constant liability to " take cold." Or it may be 
weak and relaxed from previous excitement, during fatigue or during sleep. 
Hence persons are more apt to catch cold after being in a hot room, after exertion, 
or when asleep. On the other hand, the injurious effect of cold is lessened or 
prevented by a vigorous state of the capillary circulation, whether that vigor be 
natural or excited by continued exertion, stimulating drinks, or by febrile 
excitement. 

On this view, we can understand why partial Out continued cold, such as from 
draughts of. cold air, wearing damp clothes, standing on cold stones, and the 
like, should be particularly injurious, even when the sensation of cold 
excited, is not great. Such causes of cold, acting long on the same part, more 
completely constrict its vessels, check its secretions, thus mor^ surely injure the 
balance of the circulation and by throwing a corresponding amount cf conges- 
tion inwardly, fix it in some part predisposed to disease. 

When a person has thus taken cold, which he knows by general sensation of 
coldness and weak circulation, rather than by any feelings in the part chilled, 
powerful measures which tend to restore the balance of the circulation, such as 
violent exertion, a hot or vapor bath, or stimulant drinks, may often yet prevent 
the further progress of disease. 

The general application of cold, if not long continued, is less injurious than 
that which is partial, both because it also supplies the lungs with denser air, and 
therefore more oxygen ; and its impression on the nerves of the face 
and chest excites more energetic respiratory movements, which maintain 
the heat and the vigor of the circulation. Healthy persons rarely take 
cold when traveling on the top of a coach or in a perfectly open carriage, 
but they frequently suffer in a close carriage partially open. Suscepti- 
bility to the morbid effects of cold is to be diminished by means which 
invigorate the capillary circulation, especially those which promote that process 
of reaction by which cold is naturally resisted. Now nothing tends to increase 
this more than, sudden artificial applications of cold, as by cold bathing or 
sponging, followed by friction, exercise, heat, or stimulant applications, which 
promote the reaction. The great art in usefully applying cold with these inten- 



58 Principles and Practice of 

tions consists in using the cold in such manner and degree, and having the body- 
in such a state before and after the application, that the reaction or glow, which 
is the sign of vigor in the capillary circulation, shall be most fully produced. If, 
on the other hand, the cold be applied too long, or when the body is exhausted 
by fatigue, exertion or other cause, or is naturally too weak, depressing effects of 
cold will continue ; there will be little or no reaction, and the sensations of 
languor and chilliness show that the cold has been injurious instead of 
beneficial. 

The addition of salt to the water of baths gives it a stimulant property which 
promotes reaction, and a similar influence results from the force, or shock, with 
which the water is applied. This shock excites deep and forcible respirations 
through an impression on the incident nerves, and these are probably the effi- 
cient cause of the process of reaction which follows. The reaction which fol- 
lows the judicious use of cold as a therapeutic agent, may prove serviceable, 
not only in resisting the further influence of cold, but also to remove conges- 
tions and irregularities in the circulation, and from other causes, and to excite 
in the capillaries and secernents new actions, which may supersede those of 
disease. It is thus the "water system" chiefly operates ; and although too pow- 
erful an agent to be entrusted to unskillful and unscientific hands, it is a valu- 
able addition to the means of combatting diseases, particularly of a chronic 
kind. 

In the preceding remarks on cold, it must be borne in mind that the term 
cold is applied relatively, not absolutely ; cold is not a fixed temperature or 
range of temperature, but something considerably below the temperature of the 
body. Thus, a body has been warmed throughout to a heat of 98 degrees, 
and kept in an excited state by that temperature, would suffer from a draught 
of air at 70 degrees, which would be cold to the body, and produce the physio- 
logical and pathological effects of cold. But if the body had not been pre- 
viously warmed, so that the temperature of most parts of the surface might not 
exceed 85 degrees, or if, although lately warmed, the energies of the body had 
not been exhausted by it, then air at 70 degrees would feel pleasant, and pro- 
duce none of the effects of cold. 

This is one of the many facts which distinguish vital from physical properties. 
Physical or chemical properties are generally affected by fixed temperatures, in- 
dependent of previous circumstances ; but vital properties are variously 
affected through that power of adaptation by which they are enabled to maintain 
the same function in varying external circumstances. It is thus that atmospheric 
changes in variable climates are fertile causes of disease. In some parts of the 
country, on a sudden change of wind, the temperature sometimes falls 1 5 degrees 
or 20 degrees in the course of a day, and, without any peculiar exposure, the body 
may become so chilled by the change as to suffer to a degree amounting to dis- 
ease. Internal congestions are the common result, but the seat of congestion 
and disorder will vary according to the predisposition. Thus, after the heat of 
summer, the organs most apt to suffer are the liver and abdominal viscera, 
which are disposed to d'sorder by previous excitement ; on the other hand, in 



American Medicine and Surgery. 59* 

the spring, after the winter cold, the lungs and air-passages are more prone to 
derangement. 

NON-COGNIZABLE AGENTS. 

We now proceed to notice those causes of disease, the existence of which is 
inferred only from the fact that disease prevails under certain circumstances, not 
well explained, unless we assume that causes do exist, although we cannot prove 
their existence in any other way. These comprise the endemic, epidemic, and 
infectious causes of disease. Some writers term them zymatic (a ferment), 
but inasmuch as this epithet involves a hypothetical signification of their mode 
of action, it does not seem expedient to adopt it here. 

ENDEMIC CAUSES. 

Persons living in a marshy district are often afflicted by a disease called ague, 
which does not attack those inhabiting dry lands. Again, the inhabitants of 
certain deep valleys are often affected with the swelling in the neck called bron- 
chocele, or goitre ; the neighboring mountaineers are not so affected ; and when 
those frpm below remove their residence to the mountain, they often lose the 
disease. 

These are instances of diseases which may be said to dwell among the resi- 
dents in particular spots, hence they are .called ende?nic — in the people. In 
some cases much doubt still hangs over the precise source of endemic influence; 
some supposing it to be the water, others in emanations from the soil ; but this 
doubt does not apply to the cause of agues, intermittent and remittent fevers, 
which have been clearly traced to effluvia from marshes, jungles, rice grounds, 
etc. It has been found that when the wind blows across these marshes, the disease 
appears chiefly in persons residing to leeward of them, and not to windward ; and 
has been abundantly proved that when the marshes are drained the ague ceases. 
From these and similar facts, it is concluded that the cause of ague is an efflu- 
viu?n, miasm, malaria, or bad air — an aerial poison which is supposed to be in- 
haled with the breath, and absorbed into the system. Those residing on the east 
side of a river, marsh, or swamp, will suffer from malaria, while those on the 
west side may be exempt. 

The true nature of marsh malaria has not been determined. It has never been 
detected by chemical analysis. Professor Daniel conjectured that the malaria 
causing the destructive epidemic fevers of Western Africa might be sulphur- 
eted hydrogen, evolved from the sea-water by the decomposing vegetable mat- 
ter brought down by the rivers ; but hundreds of experiments in this country 
have negatived this notion, and the latest discoveries, with the aid of the micro- 
scope, lead us to believe (while yet uncertain) that miasma is emitted in the 
form of a germ taken up by the salivary glands, and thus conveyed into the 
system. 

Although hitherto unknown in its nature, some knowledge of the general 
properties of marsh malaria has beSn obtained through its morbific effects. It 
seems to be heavier than air, for persons occupying a ground floor suffer more 
than those living in upper apartments. Water seems to absorb or destroy it,. 
for persons on board ship, or on an opposite side of a lake, are not affected,. 



60 Principles and Practice of 

t 

whilst, at a greater distance, a favorable wind will convey the pernicious influ- 
ence overland. A damp state of the air, however, favors its production. Good 
fires in a house give marked protection to the inmates. It seems to be attracted 
by trees, for the vicinity of trees is doubly dangerous ; whilst places beyond 
trees are more free from its effects than others at the same distance. The chief 
points known with regard to the sources of malaria, are, that it arises from the 
operation of the sun's heat on marshy ground, or on the banks and deltas of 
tideless rivers, after evaporation has proceeded to some extent, putrifaction of 
organic matter not being an essential part of the process. The virulence of the 
malaria, as shown in the severity of the disease excited, and in the number which 
it affects, seems to bear some proportion to the heat which has led to its devel- 
opment. Thus, the ague of this country, the pernicious of the intermittent 
•of Italy, and the malignant intermittent of Western Africa and the West In- 
dies, seem to arise from similar endemic causes, but differing in their virulence 
according to the degree of heat. A certain amount of moisture is, however, 
required, for a very dry season, which dessicates a marsh, stops the malaria, 
and the deposit of the evening dew always favors its production. Again, ex- 
cess of moisture checks its development, so that a very wet season, as well as a 
very dry o.ie, may render a marsh less unhealthy. Extreme heat, however, will 
not diminish the malaria from the banks of rivers, since portions of these are 
never dry. 

For a similar reason, all the low shores of the Mediterranean are always mala- 
rious at the commencement of hot weather, the absence of a tide preventing 
that frequent salt washing and drainage which purifies other European shores, 
while the same rule holds good as to the Mississippi in this country. It is not 
only marshy or low grounds that engender malaria, although these are the situ- 
ations commonly most favorable for its production. All that seems to be requi- 
site is the continued operation of the sun's heat on moisture, stagnant at or near 
the surface of the ground. 

I know instances in which ague has attacked persons living on a height of 
mountain lime stone, forming a small table land below greater heights. So also 
some swamply lands are not malarious, particularly peat bogs, which show a 
remarkable exemption from decomposition and effluvia of all kinds. ■ 

The morbid effects of marsh miasms are several ; intermittent and remittent 
fevers of various types are the most remarkable of these, and they particularly 
affect the new residents ; but the older inhabitants suffer from diseases of the 
liver and spleen, nervous affections, rheumatism, dropsy, and cachectic com- 
plaints, and are generally short lived. The first operation of malarial poison is 
manifest upon the nervous system, and then on the quality and distribution of 
the blood, which in the worst cases becomes speedily darker in color and other- 
wise altered, and accumulates to an extraordinary amount in internal organs, 
-where it suffers still further from its stagnation and want of purification by the 
ordinary secretions. The fit of ague is the reaction of the vital powers against 
this decomposing and cumulative influence of the poison on the blood ; and if 
the vital powers are strong, and the dose of poison not overwhelming, the fit 
successfully removes the internal congestion, and partially restores the purity of 



American Medicine and Surgery. 61 

the blood by an increase of the excretions ; but the poison being still in the 
system, reproduces similar effects after a longer or shorter interval. 

One of the most remarkable characters in the disease resulting from malaria, 
is the periodicity of their attacks, and the diminution or cessation of the symp- 
toms in the interval. This is probably due to the alternate accumulation of the 
malarious influence in the body and the reaction of the vital powers against it, 
thus showing its effect or influence upon the nervous system. 

There can be little doubt that there are different kinds of malaria besides 
that which causes intermittent and remittent fever. Thus yellow fever and 
plague are endemic diseases probably arising from aerial poison. 

The propagation and mortality of the latter, perhaps its very existence, are 
very much to be ascribed to the filth and impurities of the towns where it pre- 
vails. These are cognizable causes, the operation of which in exciting and pre- 
disposing to disease has been already noticed. Some other epidemic diseases 
can be traced to other cognizable causes ; as the Guinea worm, to drinking water 
containing its ova ; the pillagra of northern Italy, and the plica of Poland, to 
neglect of cleanliness, and unhealthy modes of living. 

EPIDEMIC CAUSES. 

There is another class of diseases, which, in their affecting many persons in 
the same place, and at the same time, resemble the endemic. But they differ in 
this respect, that they do not regularly return at stated seasons, nor are they 
confined to particular localities, although they infest some more than others ; 
they attack a whole district, a whole country, — nay, almost a whole hemisphere 
— within a very short time, then disappearing for an uncertain period, perhaps 
recurring within a few months, or years, or not within the memory of man. 

These are called epidemics, like a blight, or pernicious influence blowing on 
the people ; and therefore affecting a whole country at once. 

The cause of these diseases is supposed to be something in the atmosphere ; 
because the atmosphere is the only thing common to all the places so affected ; 
but the nature of the cause is not known. It is true that some diseases which 
seem to prevail epidemically, may be traced to the cognizable qualities, cold, 
heat, dryness, and moisture of the air. Thus diseases excited by cold sometimes 
prevail, like an epidemic in the winter ; those by heat in the summer ; catarrhs 
and quinsies abound in cold, damp weather ; croup and rheumatism become 
common during the prevalence of a cold east wind in the spring ; diarrhoea and 
dysentery are rife in the fruit season of the autumn. Others, again, such as 
dysenteries, fevers, scurvies, etc., have, in some instances, obviously arisen from 
deficient or contaminated, bad water, or some distinctly cognizable cause. And 
as these causes belong to the class of cognizable agents before noticed, it is 
unnecessary to advert to them here. 

But there are diseases occurring epidemically without any discoverable con- 
nection with season or temperature. Thus an epidemic influenza may come on 
at any season of the year, rapidly spread through a country, and cease as unac- 
countably as it began. 

So, too. diseases that are usually excited by other causes, infectious and others , 



62 Principles and Practice of 

such as typhus and scarlet fevers, measles, diptheria, small-pox, erysipelas, etc., 
sometimes prevail throughout a country so generally, and often with such pecu- 
liar character, that some influence besides their common causes must be con- 
cerned in their sudden increase. The nature of this influence is unknown ; but 
it is called epidemic. 

Lastly, various diseases, fevers and inflammations, and almost all sorts of ail- 
ments, at some periods assume a remarkable character in common, or type (as 
it is called); for example, being attended with unusual weakness, or unusual ex- 
citement, or a tendency to hemorrhage. This is called an epidemic or prevail- 
ing diathesis, or constitution. Thus, at uncertain times, fevers, wherever aris- 
ing, and from whatever source, are more low, typhoid or adynamic, than usual ; 
at the same time ex-anthematous diseases generally partake of the same charac- 
ter ; and even patients affected with inflammations do not well bear the usual 
depleting medicine. Of late years this constitution has more or less prevailed, 
and may be contrasted with a period of sixty years ago, when an inflammatory 
diathesis existed and depletion was resorted to by the old-school practice with a 
high rate of mortality, when, a few years later, depleting agents were death to 
the patient, and are so to-day. 

It has been before stated that we are quite in the dark as to the nature of epi- 
demic influence, or causes of disease. Many conjectures have been advanced, 
some of them with much plausibility, but without any substantial support. 

Dr. Prout stated that shortly before and during the prevalence of the malig- 
nant cholera in England, he noticed a small but decided increase in the average 
weight of the atmosphere, as if from the addition of some ponderous gas. 

At the same time he observed an unusual acidity in the saliva even of healthy 
persons, and such an absence of lithic acid from the urine that he seems inclined 
to suppose that a disposition to form oxalic acid was referable to the same un- 
known cause which was then producing cholera. 

Many analogical arguments may be adduced in favor of a favorite notion of 
Linnaeus, that epidemic diseases are caused by germs. The chief facts which 
countenance this view are the following : 

ist. Epidemic diseases, in the uncertain periods and places in which their vis- 
itations occur, resemble those of blights, or tribes of insects, which are known to 
appear and disappear without evident cause. 

2d. Proofs are accumulating of the occasional existence of parasitic animals 
and plants in living animals, and in some instances as causes of disease, as in 
the case of worms and other entozoa, acari in itch, the rot worm in sheep, the 
mycodermatous vegetation in porrigo, confervas in impetigo, aphthae, etc. 

3d. The history and symptoms of some epidemic diseases, such as cholera 
and influenza, are not inconsistent with the hypothesis that they are caused by 
the sudden development of germs from ova in the blood. But there is a total 
want of direct observation in support of this hypothesis, and, perhaps, it may be 
objected against it that the seasons at which epidemics sometimes appear (as 
cholera in winter) are not always those most favorable to the development of 
germ life. The prevalence of the south-east wind was observed to be particu- 
larly favorable to the increase both of cholera and influenza, and I cannot but 



American Medicine and Surgery. 63 

think that this had some connection with the general tendency exhibited by the 
former to spread chiefly from east to west. 

Has the morbific property of this wind aught to do with the haziness of the 
air when it prevails— a haziness seen in the country, remote from smoke and 
quite distinct from fog ? 

In the west of England a hazy day in spring is called a blight. 

INFECTIOUS CAUSES. 

The terms infection and contagion are applied to the production of a dis- 
ease by a morbid matter proceeding from the body of another person who is, or 
has been, the subject of the same disease. 

The proofs that disease is thus propagated from one individual to another are 
first, the general one, that those who have intercourse with the sick are infected 
in much greater numbers than those who have not ; and secondly, the direct and 
individual proof of infecting a healthy person with matter taken from a person 
in disease. 

This, although available only in some modes of infection, may be considered 
as a proof of the fact of contagion in general— that is of disease propagating its 
kind. 

I have just alluded to differences in modes of infection ; they may be further 
enumerated as fc Hows : 

1st. infection through wounds, or an abraded surface, as in hydrophobia, the 
morbid matter being contained in the saliva, or guttural mucus of the rabid ani- 
mal ; and in cow-pox, the matter being contained in the specific vesicle, and 
acting on a puncture or abraded surface. 

2d. Infection by contact, different parts of the body being susceptible of dif- 
ferent diseases, as the urethra and conjunctiva in gonorrhoea, the vicinity of the 
external openings of the passage in syphilis, the skin in scabies, the scalp in por- 
rigo— the morbid matter generally proceeding from similar parts. 

3d. Infection by exhalation from the breath, perspiration, or other secretion, 
conveyed through the air to the mouth and air passages, as in the case of measles, 
scarlatina, whooping-cough, typhus and other infectious fevers. 

Some diseases may be propagated in several of these modes ; small-pox, for 
instance, may be communicated by punctures in the skin by inoculation, appli- 
cation to the eye, and by diffusion through the air, and, probably, the same 
might be effected with other febrile poisons if their precise source in the body 
was as clear as it is in small-pox. These different modes of infection merely 
show that the infecting matter can exist suspended in the air, as well as in a fluid 
or solid state ; and, according to these conditions, it may get access to the human 
system by different avenues. 

Many of those who are skeptical as to the reality of infection aim their objec- 
tions only against aerial infection, and do not question the other modes. But 
the difficult problem is, not that the infectious matter may be diffused through 
the air — our smell informs us that animal effluvia are constantly so diffused — 
but the difficulty lies in the fact of infection by any mode, that is, that disease 
should propagate its kind. 



64 Principles and Practice of 

There are only two parallel cases in nature in which analogous proportions 
are possessed by matter. 

One is the case of what is called septic matter, leaven, or ferment, a little of 
which introduced into organized matter will promote changes and decomposi- 
tion — " a little leaven leaveneth the whole lump." This property is supposed by 
Liebig, and other chemists, to be chemical, operating in the manner of heat by 
altering the molecular relations of compound matter,; but by Turpin, Cagniard, 
De la Tour and others, it is stated that fermentation is caused by the produc- 
tion and growth of living molecules or vegetables, and that it spreads by the 
propagating power of these. This would transfer this case, that of leaven or 
ferment, into the next category. 

The other case analogous to propagation of disease by infection is the vital 
power of generation, in this case as in that of contagion, matter propagates its 
own kind in the animal and the vegetable world. Does the matter of contagion 
consist of animal ova or vegetable seeds ? Are infectious diseases the results of 
the invasions and operations of living parasites, disturbing in sundry ways the 
functions and structures of the body, each after its own kind, until the vital 
powers either tail or succeed in expelling the invading tribes from the system ? 
Such an opinion has been many times proposed, and is, in a degree, implied 
in the term incubation (sitting on eggs to hatch them), commonly applied to the 
period between the reception of the infection and the first appearance of the 
symptoms. 

In support of this motion, may be added the case of itch, which certainly 
infests by an insect, the itch mite, and spreads by this animal propagations ; 
and the case of porrigo ,or favus, which depends on a minute parasitic vegetable, 
and infests through its seeds or sporules. But these, it may be objected, are 
instances of mere local disease, and by no means like the cases of infectious 
fevers and syphilis, which affect the whole system. The case of small-pox and 
cow-pox might seem race intelligible because the infectious matter is found to 
reside in the incipient pustule, ; but this throws no further light on the subject ; 
and although M. Gruby has reported that he has found a few germs in the 
lymph of these vesicles, its disseminating property has not been traced to them. 
The parasitic nature of infectious matters may receive some support from the 
little that is known of their general properties which further deserve to be men- 
tioned on account of their practical importance. 

Infectious matter is destroyed by a temperature above 120 degrees Fahren- 
heit, and by strong chemical agents, especially chlorine ; its activity is impaired 
by cold ; and in case of seriai infection it is rendered harmless. Hence, many 
infectious diseases cease when hard frosts set in. On the other hand, warmth, 
closeness and filth increase the virulence of contagion, and become, as it were, a 
a nursery of pestilence. Nothing tends to promote the spread of an infectious 
disease more than crowding together several who are suffering under it. Each 
one is a separate source of contagion, and if these sources are multiplied in an 
apartment, the air will be contaminated in proportion. This is the chief reason 
why, in fever hospitals and fever wards, medical attendants and nurses escape 



o 



V7 

>4 



American Medicine and Surgery. 65 

infection much more rarely than in hospitals where the fever patients are widely 
distributed among other patients. 

It may be useful again to point out the peculiarities which distinguish infec- 
tions from endemic diseases ; for these peculiarities are proofs of the reality of 
infection as a separate cause of disease. 

Infectious diseases first attack individuals in any locality, then gradually 
spread in the vicinity of those diseased, or in the direction where there is most 
human intercourse. 

Where care is taken early and completely to separate the diseased from the 
healthy, disease does not appear among the latter. 

Endemic diseases may simultaneously attack many individuals in certain 
localities only ; they do not spread beyond these localities. No separation of the 
sick from the healthy will save the latter, but removing the healthy to another 
spot gives them security. 

Epidemic diseases simultaneously attack numbers in any locality ; they 
increase not peculiarity in the vicinity of those first affected, nor in proportion 
to the intercourse with them, but rather in proportion to the prevalence of other 
conditions that may be called predisposing or determining causes. 

It must not be forgotten that some diseases are suspected to originate and 
spread in two or even all of these modes. Perhaps this may be said of typhus 
fever, plague, cholera and dysentery. It has been already mentioned that infec- 
tious diseases, as small-pox, scarlatina and measles, are occasionally increased 
and modified by epidemic influences, and the same thing may be said of some 
endemic maladies. So also the aggravation of contagious and epidemic com- 
plaints by endemic impurities, makes it plain that all that class of causes may 
operate conjointly. It is under such circumstances of aggravation, or under 
those of strongly prevailing predispositions, as from famine, fatigue, confine- 
ment, or mental depression, that this class of disease becomes so destructive as 
to be called pestilential or malignant. 

The direct operation of most of this class of causes is depressing, and where 
they are strongest and prevail most, the resulting disease is one of depression, 
adynamia asthenia, or prostration of the vital powers. These causes, as 
exhibiting a noxious property opposed to life, are therefore commonly designated 
specific poisons. But there is the antagonist principle of vital resistance in the 
system which leads to various processes of reaction which may be exhibited in 
different degress according to 'he relative strengths of the poison and of this 
resisting power, and likewise often according to various cognizable agents 
which simultaneously act as predisposing, determining or co-operative causes. 
For instance, in warm weather the poisonous influences are generally strong, 
and the bodily powers weak ; the resulting disease is one of more complete 
adynamia. In moderately cold weather, on the other hand, the specific poison 
is less active, and the system is ready to react, not only against it, but against 
the cold with which it may be combined. This causes a more inflammatory 
type in the consequent disease. 

5 • 



66 Principles and Practice of 



DIAGNOSIS. 



The diagnosis of diseases is the distinction of diseases from one another. It 
may relate to diseases in their essential nature or pathology, or to those groups 
of symptoms that are classed as separate diseases by nosological arrangements. 
In other words, the object of diagnosis is to determine, either the intimate nature 
or seat of a disease, or its name and place in a classification of phenomena, 
grouped under the name of special diseases. According to the nosological 
arrangement, which has been recommended as the best at present, the division 
into special diseases is, as much as is practicable, founded on pathology, or the 
essential nature of disease ; and diagnosis should also have a corresponding 
reference to this subject. But as it has been admitted that pathology is not 
sufficiently advanced to be the sole basis of nosology, so we must avail ourselves 
of other sources of information in regard to diagnosis. 

Accordingly, much of the materials of diagnosis are the results of simple 
observation or clinical experience ; and where these cannot be analyzed by any 
more rational mode, they may be measured or valued by the numerical method, 
or counting and calculating the results in a large number of cases. 

Thus, diagnosis is chiefly derived from semeiology, and the results of clinical 
experience, arranged by pathology and statistics. In some instances the causes 
and the treatment of disease give aid in the diagnosis. Thus the malarious 
character of a patient's residence, and the efficacy of quinine in curing him, will 
contribute important evidence as to the nature of his disease. Diagnosis may 
be special ox general. 

General diagnosis comprehends the distinction between the principles or 
elements of disease, as, for example, between congestion and inflammation ; be- 
tween nervous irritation and structural disease, etc. Special diagnosis relates 
to the distinction of diseases according to their chief seat, where they have no 
particular head- quarters. 

Thus the special diagnosis of inflammations, is between inflammation of the 
parenchyma of an organ and that of its investing membrane ; or between an 
intermittent or a continued fever. 

Special diagnosis also follows and distinguishes diseases in their further dif- 
ferences of a seat or character ; as the part or extent of a parenchyma or mem- 
brane inflamed, the type of a fever, etc. 

Thus special diagnosis is a branch of special pathology, and should be aided 
by an accurate and practical nosological arrangement. The mode of distin- 
guishing between two diseases which resemble each other has been absurdly 
called differential diagnosis. It consists in pointing out the signs which are 
essential to the one and not to the other. 



American Medicine and Surgery. 67 

The signs called pathognomonic, where they exist, are the chief guides in dif- 
ferential diagnosis. The modes of investigating and distinguishing diseases 
will vary much in different cases, according to the class or symptoms that first 
present themselves. 

This may be illustrated by the following problems. General pathology hav- 
ing pointed out the general nature of a disease, it is required to determine its pre- 
cise seat. Example : In a case in which fever, hard pulse, determination of blood, 
and local pain indicate inflammation, the seat of the inflammation is determined 
by the chief seat of pain or uneasiness (in the chest or side), by the function 
most disturbed (difficult breathing and cough), to be in the organs of respira- 
tion ; by the secretion proceeding from the part (rusty, viscid expectoration), 
and from the physical signs (impaired breath-sound and stroke-sound in part 
of the chest, with crepitant rhonchus), to be in the parenchyma of the lungs ; 
that is pneumonia. General pathology here commences the diagnosis ; which 
is completed by reference to symptoms explained by physiology and special 
pathology. 

Previous history, prominent symptoms, or physical signs, having pointed out 
the seat of a disease, it is required to determine its nature. 

Example : A person suffers from severe pain at the epigastrium ; the previ- 
ous occurrence of symptoms of indigestion, and the situation of the pain, plainly 
show the disorder to be situated in the stomach ; the nature of the disease 
(whether inflammatory or nervous, etc.) is to be determined by general pathol- 
ogy ; guided by this, and finding an absence of symptoms of inflammation, no 
increased heat of surface, no acceleration of the pulse further than what the 
pain would cause, and no increase of the pain on the imbibition of warm or 
stimulating liquids ; and finding symptoms of predominate nervous proper- 
ties, and the sudden attack, intense character, and transient duration of the pain 
which distinguish nervous and spasmodic affections, we decide that the disease 
is gastralgia or gastrodynia, and not gastritis. The diagnosis which is begun 
by local symptoms is completed by reference to the principle of pathology 
Lastly, which is acommon'case, symptoms being too few or too inconclusive to 
lead the diagnosis, both the seat and the nature of the disease are to be deter- 
mined. 

A person complains of general uneasiness, weakness and chilliness, with 
various functional symptoms, but none of a prominent character. Clinical 
experience has taught the practitioner that such are the symptoms of incipient 
fever, and we proceed to investigate further the nature and cause of the fever. 
If he finds, on close examination of the functions and physical condition of the 
different organs, that one is the seat of marked inflammation, and that the fever 
is not typhoid, he judges that the fever is symptomatic of the inflammation, but 
if signs of marked local inflammation be absent, yet the fever continues with 
increasing symptoms of depression, weak, frequent pulse, brown, dry tongue, 
sordes on teeth, low delirium, etc., he recognizes typhoid fever resulting from 
the influence of a morbid poison on the system. 

Thus every department of medical knowledge is brought to bear on diagnosis 
and in no branch is the information, as well as the judgment, of the practitioner 



68 Principles and Practice of 

more brought to a test. Natural shrewdness and tact, with some general 
knowledge of the nature and treatment of disease, may sometimes enable a 
comparatively ignorant person to practice medicine with an appearance of suc- 
cess ; but such a person can make no hand of diagnosis ; and he wisely either 
avoids the whole subject or expresses his opinions in vague terms, and scrupu- 
lously avoids their being brought to the test of the scalpel. 

The well-informed practitioner, on the other hand, feels that this is the sub- 
ject which requires the full application of his mental powers and knowledge, as 
well as the keen exercise of his powers of observation ; and in proportion as his 
senses are practiced in observing, his information well arranged in relation to what 
he observes, and his judgment matured in discriminating and deciding the results 
so will he be successful in diagnosis, and in applying it to prognosis and practice. 
In investigating the symptoms of a case with a view to diagnosis, prognosis and 
treatment, the observation is first drawn to those which at once declare them- 
selves in the aspect of the patient, the expression of the countenance, the com- 
plexion, the posture, the manner of the movements, speech, etc., and these give 
important information to the observing practitioner at first sight and whilst he 
is interrogating the patient. After the first few statements of complaints, 
which are generally volunteered by the patient, the questions should be directed 
to the history of the ailment, including the previous state of health and 
habits, with regard to food, clothing, occupation, residence, etc., any former 
illness, the mode of the present attack, and its supposed cause, the former 
symptoms, and treatment, if any has been employed. 

The answers to these questions will direct the inquiries in the most searching 
manner with regard to the present state and symptoms. 

The mode of investigating these will partly depend on the clue given by the 
answers to previous questions, but the practitioner must not permit himself to be 
so far led by the patient's statements as to omit to examine the state of all the 
important organs and their functions. 

The nervous system and its functions (sensorial, sentient, excitomotory and 
sympathetic), the organs of circulation and their functions, pulse of heart and 
arteries, capillary circulation of surface and visible parts, temperature, state of 
veins, etc.,) the organs of respiration and their functions, (breathing, cough, 
expectoration, voice, arterialization of the blood ;) the organs of digestion and 
their functions, (tongue appetite, digestion, etc.;) the organs of secretion and 
excretion and their functions, (liver and intestines, kidneys, bladder and the 
skin;) the functions of ?iutritio?i and assimilation, (to be. judged of by the con- 
dition of the flesh and comparative weight of the subject ;) the organs of locomo- 
tion and their functions ; the organs of generation and their functions, are 
severally to be made the subjects of inquiry and physical examination to such an 
extent as may be requisite to inform the practitioner of their true condition and 
connection with the past or present disease. The object of a complete investi- 
gation of the state of the patient is not merely to determine the particular dis- 
ease under which the patient labors, but to discover what is healthy as weil as 
what is morbid in his condition. The prognosis, or estimation of the amount 
and event of the disease, and the application of treatment requires this full 



American Medicine and Surgery. 69 

investigation. We have to consider, not merely disease in the body, but the 
body in disease, and it is by losing sight of this great practical axiom, that 
minute or microscopic inquirers, who may be singularly successful in special 
diagnosis, signally fail in prognosis and in practice. 

1 In the examinations of patients there should be a perfect system or order 
observed, according to a well defined plan, The name, age, occupation, tem- 
perament, previous history, residence, sex, should be carefully noted and show 
inspection, palpation, measurement, percussion, pulse and heat. All interro- 
gations should be put in a systematic order so as to arrive at a precise diag- 
nosis, and a rational indication of cure. But, above all, let us never forget that 
we are examining a fellow-creature who possesses the same feelings as our- 
selves. Prudence, delicacy and kindness should, therefore, guide our move- 
ments. 

The best standard of diagnosis is between fifteen and forty-five ; then ossifi" 
cation is perfect, respiration, pulse, heat, etc., all in the conditions of perfect 
health. Inspection of the general posture of the patient in repose and in motion 
is often very suggestive. The position and attitude in fever and inflammation, 
in paralysis, hydrothorax, asthma, colic and spasmodic diseases are highly 
characteristic. The supine position denotes muscular debility, quick, forcible 
changes indicate excitement of the nervous system, while fixed or restrained 
movements are dependent on paralysis or inflammation. 

Inspection of the countenance is of great importance, observing whether 
sadness, peevishness, despair, fear, grief, or joy is evinced ; also as to color or 
conformation. Yellow color in jaundice and schirrosis. Pain in the head will 
cause the brows to corrugate ; in the chest the nostrils to be drawn upward ; in 
the abdomen, the lips to be raised and stretched over the gums and teeth. 

Inspection of the chest refers to the form and configuration of the entire 
thorax or its various parts, and a careful comparison of the two sides, whether 
in motion or at rest. The motions of the chest are referable to inspiration and 
expiration, which pass imperceptibly into one another. In disease these mo- 
tions are altered in various ways: 

1st. By general excess or diminution, as in asthma or laryngeal obstruction. 

2d. By partial immobility, as in pleurisy or augmented expansion, as in pneu- 
monia or pleurisy. 

3d. By increased rapidity, as in pericarditis, or unusual slowness as in coma. 

Inspection of the abdomen is no less important than that of the chest. In 
health it is slightly convex, marked by elevations and depressions, corresponding 
to the muscles of its walls ; the umbilicus and prominences of the viscera 
below. It varies with age and sex, smooth and flat in the young, 
broader inferiority in females than in males, from the greater width of the pelvis. 
In disease it may be enlarged, generally and symmetrically as in dropsies, 
partially or irregularly in ovarian, hepatic, splenic and other diseases ; it may be 
retracted from emaciation or intestinal obstruction. The respiratory move- 
ments of the abdomen bear a certain relation to those of the chest, and are 
increased or arrested with them. In pleurisy the respiratory movements are 
mostly abdominal, in peritonitis altogether thoracic. 



•jo Principles and Practice of 

Disturbed relations of the respiratory movements of both abdomen and thorax 
are useful points in diagnosis in hydro-thorax, asthma, anasmia, ascites, abdomi- 
nal tumors, etc. 

Palpation. This is a valuable mode of examination, and is practiced by sim- 
ply applying the tips of the fingers or the whole hand, or both, and pressing with 
them. The most favorable position for palpation is the horizontal or erect posi- 
tion. The information that palpation gives us is — 
ist. Increased or diminished sensibility. 

2d. The altered form or shape, size, density, elasticity, etc., of the parts under 
examination. 

3d. The different kind of movements to which they are subjected. 
Pain, if inflammatory, is increased on pressure, but relieved if neuralgic. 
In paralysis the diminuition of sensibility can only be ascertained by feeling 
the part, and the limitation of the anasthesia is best arrived at by pricking of the 
surface. 

Alterations in size, form and density are often exactly made out by palpation ; 
a change inelasticity, hypertrophy or atrophy, is also easily determined. Cer- 
tain motions, as expansion and contraction, vibrations, frictions, grating, crepita- 
tion, are also easily determined by palpation. The natural premitus, or thrill 
perceptible on placing the hand on the chest when a person speaks, is increased 
or diminished in disease. Fluctuation is a sensation caused by pressing on or 
percussing parts in such a way as to cause displacement of their contained 
fluids. 

Mensuration. This is another valuable mode of examination, and consists in 
measuring the distance between any two points by a graduated tape. In ascer- 
taining the circular measurement of the chest or abdomen, that moment should 
be selected when the patient holds his breath at the end of an ordinary expiration, 
great care being taken that the tape is carried evenly round the body. For 
measuring either side of the chest or abdomen, a spinous process of the verte- 
bras should be taken as a fixed point, and the middle of the sternum or umbili- 
cus for the other. The exact levels of the measurement should be carefully 
noted, and an allowance of an inch or an inch and a half of the right side. The 
pressure of the stays in a female enlarges the thoracic, and diminishes the ab- 
dominal movements. Mensuration is valuable in pleuritis, pneumonia, incipient 
phthisis, emphysema. An allowance of from one to two inches should be made- 
whether the patient be a right-handed or left-handed person. The expansibility 
of the lungs, and the amount of air expelled from the chest after a full expira- 
tion, may be accurately measured by the spirometer. 

Percussion. The object of percussion is to ascertain the resistance and size 
of organs. It may be performed directly or through the medium of an inter- 
posed body, as the fingers or pleximeter (mediate percussion); it is best per- 
formed by spreading the fingers of the other hand. The ivory pleximeter pos- 
sesses no advantages over the fingers. 

The sounds produced by percussion arise from the vibrations occasioned in 
the solid texture in the organs percussed. The different density ajid elasticity 



American Medicine and Surgery. yi 

of these textures modify the number and continuance of the vibrations, and give 
rise to different sounds. 

The sounds obtained by percussion are, essentially, three ; and these three 
sounds are respectively dependent, first, on the organs containing air ; second, on 
its containing fluids, and third, on its being formed of a dense, uniform parenchy- 
matous tissue throughout. These tones, therefore, may be termed the tympan- 
itic, the humoral, and parenchymatous. 

The terms femoral, cardiac, intestinal, hydatic, may be used to express some 
modification of sound produced in percussing the heart, intestines, etc. To be- 
come thoroughly conversant with those sounds, practice and perseverance are 
indispensable. 

The sense of resistance is an important consideration in percussion. It bears 
a relation to the density of the object struck — thus, firm and solid textures offer 
more resistance than the soft or elastic ones. The thorax of a child is elastic, 
that of an adult unyielding. 

Before proceeding to percuss individual organs in persons laboring under dis- 
ease, a clear and accurate knowledge of the limits and intensity of dullness on 
percussion of the thoracic and abdominal viscera in health should be well un- 
derstood. Over the region of normal lungs, we have a clear tympanitic sound, 
Congestion or effusion of tubercle in its first stage may cause slight dullness and 
increased resistance, which only careful percussion can detect; but, in a more 
advanced stage, the dullness and increased resistance are well marked, and even 
an impression of hardness and solidity is communicated to the hand. Tuber- 
cular effusion takes place by affinity in the apex of the lungs. Inflammation at 
the base, when congestion or induration exists in those portions of the lungs 
which overlap the liver ; it requires nice discrimination to detect it with certainty 

Fluid may be detected in the pleural cavity by percussing the patient in the re- 
cumbent position, where if but little exist there may be no unnatural dulness ; 
but let the patient sit up, then the height or level of the fluid may readily be 
determined, and should be marked by a line of nitrate of silver. If the effusion 
fills the pleural cavity, no limit can be placed to the area of dullness. If the 
lung is emphysematous, or if air be present in the pleura, the sound becomes 
unusually tympanic. The diagnosis of affections of the heart constitute the 
most difficult in the art of medicine. Its size can be easily appreciated and any 
abnormal deviations detected. Its size varies, but a normal heart should 
occupy an area of dullness equal to the closed fist of the patient, but in effusion 
between the pericardium and heart, the area of the dullness may be great, so also 
in the various forms of hypertrophy. It may bulge out in pericarditis. It is, 
necessary to be cautious in percussing the liver, so as to determine its bounda- 
ries ; the superior limit of this organ is generally found about two inches below 
the right nipple ; its inferior border descends to the lower margin of the ribs ; 
variations in the size of the liver from congestion, inflammation, abscess, hyda- 
tids, tumors or atrophy may be exactly made out by percussion. In icterus, the 
increase and diminution of this organ will be found to bear a proportion to the 
intensity of organic disease. If the gall-bladder is distended by bile, or con- 
tains gall-stone, it is usually detected by percussion and the dullness under the 



72 Principles and Practice of 

inferior margin of the liver anteriorly and somewhat laterally, may be marked 
out. 

The size of the spleen is four inches long and three inches wide. In diseased 
states it may be atrophied or enlarged. In percussing this organ place the pa- 
tient on the right side. The sounds elicited on percussion of the stomach and 
intestines are of great value in determining the form of other organs as the 
liver, spleen, bladder, abdominal tumors and effusion of fluid. 

To obtain a correct appreciation of the kidneys by percussion, the patient 
should be placed on his abdomen, so as to give us a clear appreciation of the 
renal organs. 

A correct appreciation of the state of the bladder is derived by percussion. 

Auscultation. The object of auscultation is to ascertain and appreciate the 
nature of the various sounds which occur in the interior of the body, and its 
utility is limited to the pulmonary and circulatory organs. It consists in apply- 
ing the ear to the part, or indirectly through the stethoscope. 

Before resorting to auscultation it is absolutely necessary that the student or 
practitioner be thoroughly conversant with the normal sounds. This must be 
learned from the living patient, never from books or lectures. Place your ear 
over the larynx and trachea of an adult male in perfect health, and you will hear 
two noises, one accompanying inspiration and the other that of expiration, 
called the laryngeal and tracheal sounds, or murmurs. 

Move the ear to the right or left manubrium of the sternum and you will 
hear the same sounds diminished in intensity ; these are the bronchial sounds 
or murmurs. 

Place the ear under the nipple of the right side and two fine murmurs will 
be detected — normal vesicular respiratory murmurs — keep the ear in the same 
place and have the individual speak, and there will be a peculiar resonance of 
the voice called pectoriloquy or bronchophomy. 

With regard to these healthy sounds, it should be remembered that vocal reso- 
nance originates in the larynx, and diminishes or increases according to the 
distance of any point from the source of sound, and also to the power which 
the textures have in propagating it. Now, in all affections of the lungs, these 
natural sounds are altered ; new abnormal sounds are developed. 

The alterations of the natural sounds in diseased conditions may be increased, 
diminished, absent, or location changed; the most common alterations are in 
intensity, often stronger in one place than in another, or on one side (puerile 
respiration) indicating increased action at one part and diminished action at 
another. There may also be an alteration in character, the sounds becoming 
harsh, as in pneumonia; cavernous, when a cavity is formed, as in phthisis, 
amphoric in pneumo-thorax. There may also be an alteration in position, that 
is, that sounds which are natural to certain parts of the chest are heard dis- 
tinctly at places where in health they are never detected ; for instance, in pneu- 
monia, bronchial or tubular breathing may be evident where only a vesicular 
murmur ought to exist. The inspiration in health is three times as long as the 
expiration, but, in certain diseased conditions, this relation is altered or inverted. 



American Medicine and Surgery. 73 

All the abnormal sounds may be classed under three heads : first, rubbing or 
friction sounds ; second, moist rattles ; third, vibrating murmurs. 

1st. Rubbing or friction sounds are caused by some morbid change in the 
pleura, as effusion in pleurisy, where, instead of sliding noiselessly on one an- 
other, they emit a rubbing sound like the rustling of two pieces of silk or brown 
paper, or grating, rasping, and between these extremes we have every interme- 
diate degree of friction noise. 

The sound will depend upon what change the inflammation has produced, 
either a thick exudation, when the sound will be louder ; should it be hard, 
dense or rough, there is a harsh or grating noise present in the various forms of 
pleurisy and pericarditis. 

2d. Moist rattles are produced by bubbles of air traversing in a viscous fluid. 
They occur in the bronchial tubes when they contain liquid exudation, as mu- 
cous, or pus, or ulcers in some cases, so fine as to be scarcely audible (crepita- 
ting), so coarse as to resemble gurgling or splashing (cavernous), and between 
these two grades we may enumerate a large number of rattles, as mucous, sub- 
mucous, subcrepitating. . 

For all practical purposes the term moist is applicable to all. 

These rattles are heard in pneumonia, phthisis, apoplexy. 

3d. Dry vibrating murmurs arise when the air tubes are obstructed, lose 
their elasticity, or are affected with spasm or thickening, whereby the vibrations 
into which they are thrown by the column of air produce tones of an abnormal 
character. The murmur is dry and the fineness or coarseness of the sound 
will depend upon the calibre of the tube or cavity thrown into vibration. Mur- 
murs may exist from a fine squeaking or a hoarse snoring, common in asthma, 
dry bronchitis and emphysema. 

Circulating organs in health or disease. In putting our ear to the heart we 
should pay attention to the impulse, to the character and rhythm of the sound, 
to the place where they are heard loudest, and the direction in which they are 
propagated. 

First find the spot where the apex of the heart beats against the walls of the 
chest, then listen to the sounds. Place the ear a little to the inside of the nipple 
near the margin of the sternum and listen to the sounds there. In the first 
position yo-: will hear the systolic sound ; in the second the diastolic sound. 
There are two sounds, then, heard over the region of the heart. The first is 
dull, deep ; more prolonged than the second, coincides with the shock of the 
apex of the heart against the thorax and immediately precedes the radical 
pulse. It has its maximum of intensity over the apex of the heart, below the 
inside of the nipple. The second sound is sharper, shorter, more superficial, 
has its maximum of intensity nearly on a level with the third rib and a little 
above and to the right of the nipple, near the left edge of the sternum. These 
sounds have received the name systolic, (contraction) and diastolic, (dilation.) 
The two sounds are in couples : 

1st. There is the long, dull sound, coinciding with the contraction of the 
heart. 

2d. There is a short pause. 



74 Principles and Practice of 

3d. The shcrt, sharp sound. 

4th. A longer pause. All of which correspond with one pulsation. 

With the systolic (contraction) sound we have the striking of the apex 
against the thoracic walls, then contraction of the ventricles, then rushing of 
the blood through the aortic orifices, followed by flapping of the auriculo-ven- 
tricular valves. 

With the diastolic (dilating) sound, we have rushing of the blood through 
the auriculo- ventricular valves and flapping together of the aortic valve . 

In disease there may be a modification of the sounds heard in hea h. and 
also new abnormal sounds developed. The modifications of healthy sounds 
are variations in their seat, intensity, extent, character and rhythm. 

For example, the sounds may be heard at their maximum intensity lower 
than their natural point in cases of dilated hypertrophy of the left ventricle, 
enlargement of the auricles, or tumor at the base depressing the organ. 

They may be higher owing to some abnormal swelling, or more on one side 
than another by effusions of fluid or air in the pleural cavity. 

The intensity and extent of the sounds may be diminished where the heart 
is atrophied or softened, when there is pericardial effusion etc., concentric atrophy' 
of left ventricle, or emphysema. The intensity and extent of the sounds are 
increased in cases of dilated hypertrophy, nervous palpitation, or when the 
adjacent parts of the lung are indurated, as in pneumonia and phthisis. The 
character of the sounds may be clearer or duller than in health, according as 
the walls of the heart are thinner or thicker. Often the sounds are muffled in 
cases of hypertrophy or softening of the muscular walls or when there is 
effusion between the pericardium and heart. Sometimes they are rough 
generally due to inflammatory change. The frequency of pulsations varies in 
different affections. In certain diseased conditions the beats are intermittent, 
in others irregular. There may also be a variation in sound ; several sounds 
may be heard, then a sort of intermission depending either upon reduplication 
in the action of the valves when diseased, or on a want of synchronism be- 
tween the two sides of the heart, sometimes from increased or irregular action 
of the organ, the sounds are bounding or tumultuous. All the diseased or new 
sounds of the heart may be classed under two heads : 

1st. Friction murmurs. 

2d. Blowing or vibrating murmurs. 

The friction sound originates from inflammatory causes, same as friction sound 
in pleurisy. The vibrating murmurs depend on some organic change, generally 
the product of inflammation. These murmurs vary in character from a gentle 
blowing or puff from the nozzle of a bellows (bellows murmurs,) whilst others 
are harsher, grating or sawing ; but all caused by some diseased condition of 
the valves. Sometimes the valves do not close and as a result the blood regur- 
gitates through them ; in some cases the valves are constricted, indurated, 
roughened and calcareous. The abnormal sounds may be single or double 
and have their origin either in the auriculo- ventricular or arterial valves, or in 
both. These sounds often resemble musical notes, more or less resembling the 
cooing of a dove, singing or whistling ; all depending upon some excessive 



American Medicine and Surgery. 75 

narrowing of the orifices, perforations of the valves, irregularities in their mar- 
gins, or exudations on their surface. 

Not unfrequently a soft systolic blowing is audible at the base of the heart, 
or over the carotid and deep jugular vein, sometimes it is continuous, resembling 
the humming of a top. These murmurs are distinguished from valvular ones 
by being systolic at the base of the heart, by their softness, by their not being 
permanent, by their occurring in anaemic or debilitated persons or young girls- 
On listening over the arteries in the vicinity of the heart, we hear the same 
sounds as are produced at the sigmoid valves propagated along its course, but 
more distinctly as we move away from the base. Often we, can detect a double 
murmur if near an aneurismal pouch. 

On applying the ear to the abdomen in health, there are gurgling and churn- 
ing noises heard, caused by the displacement of gas and water, most audible 
after a cathartic. In peritonitis the friction or grating sounds are heard owing 
to the roughening of the peritoneum by inflammatory effusion. No conclusion 
as to the nature of the disease should be positively relied on by auscultation 
and percussion alone without a knowledge of all the circumstances ot the case. 
They are only modes of reaching an end. There are also other valuable means 
of diagnosing certain diseases, as the diathesis, temperament, of the pulse by 
the sphygmograph, the kidneys by the chemical examination of the urine, the 
strength by the thermometer, the internal condition of the organs by the endo- 
scope, the amount of tubercular exudation in the lungs by the spirometer. 

Temperaments. No practitioner can be successful unless he possesses a 
thorough knowledge of the temperaments. A description of these has been 
given under the head of " Predisposing causes of disease." 

THE PULSE. 

The Pzdse. The pulse varies with the age of individuals ; at birth it beats 
from 130 to 140 in a minute ; mean rate for the first month, is 120 ; limits dur- 
ing the first year, 106 to 120; for the second year, from 90 to 100, for the 
third from 80 to 90 ; nearly the same for the fourth, fifth and sixth years ; in the 
seventh year pulse about 78 ; from the twelfth year it differs but little from that 
of adult age, which is estimated at from 60 to 80, according to individual con- 
stitutions, etc. The common standard of frequency may be placed at from 70 
to 75 beats in a minute. From the 45th to the 60th year the pulse gradually 
becomes slower, after this period, it again rises in frequency. Generally more 
frequent in women than in men. Climate influences pulse, more frequent 
in hot than in cold countries. 

The time of day, slower in the morning than at other times ; most frequent 
soon after dinner ; slower during sleep than in the waking state. Bodily exer- 
cise accelerates the pulse ; varies according to the position of the body ; strong- 
est while lying down ; slower when sitting than when standing. Mental excite- 
ment influences the pulse ; joy and anger renders it fuller and more frequent, 
grief, sorrow and fear depress it. 

Mode of Examining the Pulse. — Not to be examined immediately on enter- 
ing the patient's room ; the examination to be repeated at short intervals; should 



j6 Principles and Practice of 

be felt in both wrists, the arm having its muscles relaxed by proper positions ; 
two or three fingers to be applied to the artery ; thirty or forty pulsations are to 
be felt at each examination; examined indifferent positions of the body; talk- 
ing must be forbidden. 

Pathological condition of the pulse considered in relation — 

ist. To the force of the pulsations. 

2d. To the rhythm or mode of the pulsations. 

The most prominent and useful pathological states of the pulse consist in 
frequency, quickness, strength, fullness, hardness and irregularity. 

A frequent pulse is one in which the pulsations succeed each other with pre- 
ternatural rapidity ; a pulse beating more than 160 in a minute is scarcely to be 
counted ; great frequency of pulse always connected with great prostration of 
the vital energies ; frequency with fullness and strength of pulse, more danger- 
ous than the same degree of frequency with softness, moderate fullness. When 
it rises above 120, in inflammatory fevers, much danger is to be apprehended. 

Slow pulse, occurs from cerebral compression, internal venous congestion, 
and impairment of the vital energies ; as in apoplexy, congestive fevers, and 
malignant fevers. 

Quickness of pulse, often confounded, improperly, with frequency. Quick- 
ness refers to the suddenness with which each individual pulsation is made; 
frequency has reference to the number of pulsations in a given time. Quick- 
ness, however, is generally attended by frequency. 

A strong pulse, is one which gives the sensation of preternatural resistance 
to the finger, during the diastole not to be confounded with a hard pulse. It is 
hard when the artery is feL firm under the finger like a tense cord, both in its 
systole and diastole, sometimes called corded. Strength and great frequency 
never united, a strong pulse seldom exceeding 115 beats in a minute ; a strong 
pulse indicates energy of the vital powers, and is therefore favorable. 

A feeble pulse, the reverse of a strong pulse, it is feeble, when the artery pro- 
duces a weak impulse against the finder during its diastole.' 

Feebleness and softness of pulse not synonymous — the artery may resist pres- 
sure, and yet pulsate very feebly. The pulse is soft when the artery appears 
to be filled, and yet affords no resistance, vanishing by the slightest pressure. 

A very soft pulse seldom attended with great frequency, or with irregularity, 
occurring in the advanced stages of fevers, favorable, when joined with great 
difficulty of respiration and suffused countenance, in pneumonic inflammation, 
indicative of much danger. 

Full pulse — never very frequent, sometimes much slower than natural. 

Small pulse — the diameter of the artery is smaller than natural ; in inflam- 
mations seated above the diaphragm, the pulse is generally full ; when seated 
below it is small. 

Depressed pulse — small, and apparently feeble, and occasionally quick, does 
not depend on actual debility or exhaustion, but on internal venous congestion. 
Blood-letting will raise this pulse ; distinguished from a small and weak pulse, 
by attending to the prevailing diathesis, by suffering a few ounces of blood to 
flow and watching its effects, and by observing the period of the disease in 



American Medicine and Surgery. 77 

which it occurs ; if it is small and obscure in the beginning of acute diseases, 
we may presume it is depressed. 

Intermittent pulse, when not attended by ether alarming symptoms, not in 
general a dangerous sign ; pulse sometimes habitually intermits ; it is said to be 
of dyspeptic origin ; occurs frequently in old age, and then probably depends 
commonly on some affection of the heart ; occurs also in affections of the brain ; 
a very unfavorable sign in the advanced stage of fevers, with great prostration ; 
it is said frequently to precede a critical diarrhoea. 

Unequal pulse, synonymous with irregular pulse, characterized by a constant 
variation of the pulsations, in frequency, quickness, size, hardness, etc. More 
dangerous than an intermittent pulse. 

Dicrotits pulse, twice beating. 

Gaseous pulse; tumid; inflated soap bubble ; always indicates much prostra- 
tion. 

Undulating pulse. A wave-like rising and falling of the pulse, generally 
large, soft, feeble. When very small it is termed creeping, highly dangerous. 

A morbidly natural pulse, occurs in malignant fevers, exceedingly unfavor- 
able ; can only be distinguished from a healthy pulse by the concomitant 
symptoms. 

Shattered pulse. Pulse feels like a shattered quill under the fingers ; occurs 
in opium eaters. 

Obstructed pulse. Artery remains equally full during its diastole and systole, 

THE COMPOUND PULSES. 

The principals are the synocha, synochus, synochuta, typhoid and typhus. 

1st. Synocha. Hard, full, frequent and strong ; indicates high, inflammatory 
excitement. 

2d. Synochus. Full, round, active, but not hard ; occurs in the hot stage of 
intermittents, in remittents, etc. 

3d. Synochuta. Quick, tense, small, hard, vibrating ; occurs in sub-acute 
rheumatism, inflammation of the intestines, peritoneum, etc. It is the hectic 
pulse. 

4th. Typhoid. Quick, small, slightly tense, not hard, and somewhat 
frequent; in the advanced stages of bilious fevers ; the result of irritation in 
an exhausted state of the system. 

5th. Typhus. Small, very frequent, somewhat quick ; occurs in the advanced 
stages of jail, hospital, and other varieties of typhoid fevers. 

THE TONGUE. 

We will now turn a brief attention to the morbid appearances of the tongue. 
It is by these, and the secreted products, that we obtain our most direct 
intelligence from the internal viscera, though other less sensible results may be 
more significant of the nature and force of disease. The tongue is covered by 
a secreting membrane whose action is liable to great and various changes and 
which are attended by visible results. , In its healthy state this membrane is 
covered by a thin fluid, which is partly composed of its own mucous product, 
and in part of saliva. The natural color of the tongue is a light florid hue, and 



yS Principles and Practice of 

it is studded with short minute papilla?, particularly at its edges. In disease 
these apparences are apt to undergo various changes ; the tongue being covered, 
more or less, extensively, with a coat of variable hues, white, yellow, brown or 
black, barely attached, or closely adherent, rough or smooth, etc. At other 
times the organ is preternaturally red or livid, dry or moist, enlarged or con- 
tracted, pointed or obtuse ; its natural coat thickened or apparently scraped off 
or covered with patches, vermiform marks, etc., its edges jagged, the papillae 
enlarged and elevated, etc. These conditions depend upon various modifica- 
tions of the organic functions of the tongue, and as the organ is not much 
liable to independent disease it is obvious that its morbid aspects are mostly 
sympathetic results ; and from its being continuous with the alimentary canal 
and the lungs, morbific influences are readily propagated upon it from either of 
its remote connections. But the vital relations of the tongue to the alimentary 
canal are far greater than to the lungs, though riot strongly pronounced in 
health, and as intestinal derangements are more common than pulmonary, a far 
greater proportion of the morbid and intense influences from these two sources 
are exerted by abdominal disease. The coating which forms upon the tongue 
may consist mostly of mucus, or of a substance resembling coagulable lymph, 
or intermixtures of both, in various proportions, and of a morbid character. 

All the phases which the tongue is liable to undergo may be influenced by 
the peculiar constitution of the patient, though, in a general sense, where the 
constitution is sound, these appearences are less subject to the contingencies of 
temperament than many other symptoms. We often observe, under variou ; 
circumstances of disease, that the coating has suddenly disappeared, and we 
may be led into error in consequence, since, in many of these cases, the coating 
has been removed by the mechanical friction of food. 

It would be in vain to attempt a definition of the various changes in the 
aspect of the tongue produced by disease, according to- its nature and seat, 
accidental causes, etc. The appearances may vary much under apparently the 
same conditions, and it is not one symptom alone which may attend the tongue 
but the whole in combination that must guide our judgment It is important 
also to observe that the tongue may be very natural in profound disease, even 
of the alimentary canal and liver ; but, as observation enlarges, and the depths 
of physiology are explored, we shall find the morbid signs of the tongue a 
luminous index of disease. But there is one remark more important than the 
rest, namely, that there are no other symptoms which borrow so much light 
from others as those which relate to the tongue while, in their turn, they reflect 
back a light upon other symptoms. Inflammations of various parts and 
idiopathic fevers, at their outset, may present nearly the same appearance of 
that organ, especially as it regards the coating. 

The general symptoms now contribute largely in determining the import of 
the tongue, though we shall generally find, on close inspection, that not only 
each class of diseases will offer certain peculiarities in the morbid aspects of 
the tongue, but as inflammation may effect one important organ or another, and 
the appearances will vary in the early stages of idiopathic fever as the burden 



American Medicine and Surgery. yg 

of disease may happen to be distributed. In the progress of the same affections 
the tongue is continually fluctuating in the indications it may supply. 

The disappearance of the coating in fevers and inflammations generally begins 
at the edges of the tongue, and is commonly indicative of an improvement in 
health, though not always. When these exceptions occur some other morbid 
appearance is apt to follow immediately, as preternatural redness, or nakedness, 
or dryness, etc. 

If indicative of improvement the tongue commonly clears up fast along with 
other auspicious changes, though it will be frequently kept up, more or less, by 
remaining although slight, visceral derangements in the abdomen. Absolute 
diseases of the digestive organs affect the tongue more variously and directly 
than other parts, according to their nature, seat, intensity, duration, peculiarities 
of the constitution, habits, etc. 

The following will be found reliable in making up a diagnosis based, in part, 
on the appearance of the tongue : 

Transverse fissure, intestinal irritation. 

Longitudinal tracks, kidney irritation. 

Sharp-pointed, nervous irritation. 

Large, flabby, glandular disease. 

Red tip and edges, sharp-pointed, white coat in middle, chronic gastritis. 

Smooth, raw beef tongue, inflammation of stomach. 

A thin, white, even layer, gastric irritation. 

Large, flabby, tremulous, creamy, delirium tremens. 

Tremulous and patient darts it out, as in chorea. 

Buff coat, very dry, sharp-pointed, perhaps papilUe elevated, typhoid fever. 

Thick coating, in greatest extent, white or brown, in mal-assimilation. 

Peculiar buff leather appearance, in cases of enteritis and hepatitis. 

Dark or charcoal hue at root, blood poisoning. 

Yellow or gingerbread, bilious. 

Dark brown, malignant fever. 

Strawberry color, surface generally coated, papillae projecting remarkably, 
scarlatina. 

A less projection through a thin, white coating, still red and moist, often ac- 
companies hysteria. 

Shining and glazed, especially when chapped, alconotus of bowels. 

Apthas and ulcerations, imperfect nutrition, mal-assimilation, the action of 
air and light generates microscopic parasites. 

Patchy tongue, chronic irritation of bowels. 

Heavy white coat and occasionally red papillae, gastric fever. 

White mucus membrane, elevated, very moist, gastric catarrh. 

Tongue drawn to one side, caused by effusion upon base of brain on opposite 
side. 

THE SKIN. 

Peculiarity, thin and detached from subcutaneous structure in phthisis. 
Same, but in a less degree, in all wasting disease. 



80 Principles and Practice of 

A feeling of fullness and tension in all eruptive fevers, amounting to a sense 
of hardness in erysipelas, and producing a gritty feeling in small-pox. 

Nails chubbed and hair falls off in tubercular disease. Hair falls off in sec- 
ondary syphilis and in recovering from fevers. 

Dry, harsh skin, most marked in children, in disease of abdomen, especially 
of a tubercular character. Remarkably soft and moist in delirium tremens. 

Perspiration profuse and sour in acute rheumatism. But in some of the 
most intractable forms of disease it is also very sour; an excessive perspiration 
of any kind is often attended with miliary sudamina. 

Colliquative sweats c mstantly attend later stages of phthisis, and on profuse 
suppuration, such as lumbar abscess. 

Rigor, as in cutis anserina?, is a common precursor of fevers. 

The cracking emphysema is very characteristic. 

So is the doughy character and pitting under pressure of anasarca. 

Rigor occurring during process of inflammation, indicates formation of pus. 

Slight rigor in heats and colds indicates nervous depression. 

Protuberant eyeballs, wasting of tissue. 

THE APPETITE 

Becomes in diabetes, voracious. 
In mesenteric disease, craving. 
When intestinal worms exist, capricious. 

In hysteria, depressed, morbid, eating chalk, slate pencils, etc. 
In pregnancy, fanciful, longing for certain articles of food, apt to be abnor- 
mal. 

In dyspepsia, very variously altered. 

THIRST. 

In diabetes, remarkably increased. 
In cholera, very urgent. 
In diarrhoea, urgent, but less than cholera. 

Diuresis, with uncommon thirst, when there is no sugar in the urine, general- 
ly due to hysteria, not attended with hunger, low specific gravity. 

ALTERATIONS OF COLOR. 

In all varieties of anaemia, remarkably white. 

In anasarca, from albuminuria, same. 

Phlebitis, milk whice. 

Nervous irritation, marbly whiteness. 

There is a certain yellowness of the malignant aspect, which is distinguished 
from jaundice by the pearly lustre of the eyes. 

The yellowness of jaundice varies from a pale to a deep green yellow. 

Redness of skin, when local, indicates congestion, when general, is more fre- 
quently due to measles or scarlatina, or simply to febrile heat, it is the marked 
characteristic of erysipelas, erythema, gout" and acute rheumatism. 

In disease of the spleen the skin has a muddy hue. 



American Medicine and Surgery. -8i 

In Asiatic cholera, blue, also in forms of bronchitis, diseased heart, and in 
morbus curruleous cyanosis. 

Livid in commencing gangrene, and might also sometimes be called livid in 
disease of the heart. 

Spots and patches of discoloration, valuable in recognizing certain fevers, pur- 
pura, and scurvy, colica pectorum, nitrate silver, syphilis and most cutaneous af- 
fections. 

In Addison's disease, bronzed. 

In a stage of shock blueness of skin may be expected in many cases of ma- 
larial fever. 

The skin is of a peculiar uriniferous color and odor jn uraemia. 

Purple spots or patches in purpura or scurvy. 

SENSATIONS. 

Flushes of heat, alternated with coldness, we find in nervous derangement. 

An aura epileptic sensation, as of a gust of air on side of neck and head' 
•or up the arm, and sometimes a creeping sensation up the leg, in epilepsy. 

Numbness and pricking sensation, (as in a limb asleep,) in paralysis. 

There is a contrast in genuine cholera between the corpse-like coldness of 
-the body and the sensation of heat with which the patient is oppressed. In di- 
arrhoea there is generally chilliness. 

The common complaint in fever of chilliness when the skin is hot is a sensa- 
tion of an opposite kind. 

The hypochondriac's sensations are opposed alike to the evidence of the 
senses and the conclusions of reason. 

A patient's complaint of a want of sleep is almost sure to be exaggerated. 
The attendant's statement is alone to be relied on. 

The sympathetic pains are important. 

Pain in the right shoulder is indicative of inflammation of the liver, 

Pain of the sacrum, of disease of the uterus. In the knee, indicative of the 
hip ; of the meatus, of stone in the bladder. At the orifice of the urethra, 
thigh and testicles, ovary, of inflammation of the kidneys, nephritis or nephral- 
gia. In the cerebellum, of exhaustion of the lumbar portion of the spinal 
chord, A feeling as though the upper part of the scalp is rising indicates irri- 
tation of the pneumogastric nerve and its recurrent branches. Drowsy, sleepy 
sensation (coma) is due to bile, or urea in the blood. 

Pain, anterior and posterior, over -chest and abdomen, is indicative of car- 
cioma. 

EMACIATION SEEMS TO AFEECT. 

In phthisis the arms and thorax most, face least. 

In abdominal disease, the lower limbs and face. 

In malignant disease, the general features, ncrease of bulk becomes re- 
markable. 

When upper half of body is anasarcous, and not the lower half, or when ore 
limb is cedematous. 
6 



82 Principles and Practice of 

When the head is enlarged, in chronic hydrocephalus. 

When one side of the chest projects from the effusion of fluid, or internal 
humor, or one side of the abdomen from the same cause, the aspect is very 
significant. 

A delicate appearance, with long fringed eye-lashes, often points out the tu- 
bercular diathesis. 

Thickened alas of nose and upper lip, of scrofula, most marked in childhood. 

The pallor of anaemia is very important. 

In chlorosis, waxy, greenish. 

In kidney disease, pasty. 

A puffy appearance about the eye-lids, along with anaemia, is indication of 
albuminuria. 

The sallow hue of malignant disease appears to be only another form of 
anaemia. 

I n heart disease and chronic bronchitis the blue color, especially of the nose 
and lips, is remarkable, and contrasts strongly with the dusky flesh' of pneumo- 
nia, or the hectic flush of phthisis. 

In typhus, congested features and suffused eyes are exceedingly characteris- 
tic. 

Irregular habits of' living, generally indicated by a bloated, blotchy face. 

In erysipelas, parotitis, facial paralysis, etc., the features undergo remarkable 
• change. 

POSTURE AND GAIT. 

Inability to stand depends on weakness, vertigo or paralysis. 

In weakness and vertigo the patient reclines, in paralysis he sits. 

In curvature of the spine and disease of the hip the body is bent to one side. 

In excitement the gait is quick. 

In debility, slow. 

In diseases of the brain and paralysis, laborious, staggering or uneven. 

In rheumatism and disease of joints, stiff and halting. 

In chorea, constant moving. 

In nervousness, tremor, and, more especially, in delirium tremens. 

Tonic spasm occurs in tetanus, disease of the spinal chord, poisoning with- 
strychnine, etc. When long continued it is probably associated with inflamma- 
tory softening of the brain. 

Catalepsy is a peculiar form of tonic spasm, cramp is its mildest manifesta- 
tion. 

Clonic spasm occurs in epilepsy, eclampsia, chorea and hysteria; subsultus is 
also a form of clonic spasm, allied to tremor. 

In mania and delirium, the muscular movements generally are exalted. 

The muscular movements are diminished' generally in idiocy and imbecility, 
and lost in paralysis. A certain restlessness sometimes belongs to hypochon- 
driasis, and more rarely to hysteria, allying them with delirium in the external 
manifestation. 



American Medicine and Surgery. 83 

POSITION IN BED. 

Head chiefly elevated, in disease connected with the heart, less frequently in 
disease connected with the lungs. 

Head leans forward when there is pressure on trachea. 

Patient may be unable to lie down from pain of head or giddiness. 

Lying on the back is the position of debility ; it is then combined with list- 
lessness. Also position of paralysis, when combined with inability to alter it ; 
also, of stiffness and pain in acute rheumatism, when chiefly characterized by 
stillness. Same position generally assumed in peritonitis, when combined with 
drawing knee up towards abdomen. 

A prone position is generally only assumed in abdominal spasm or colic, 
sometimes, but much more rarely, in consequence of the pressure of an internal 
tumor. 

When fixed on one side we may generally assume that the breathing is much 
obstructed in the lung of the side on which he lies; when he is unwilling to 
turn to either side it is commonly from the sense of pain accompanying inflam- 
mation ; pressure produces pain on the affected side, while turning on the op- 
posite, causes a sensation of dragging ; a doubled up position with or without 
vomiting is present in colic, the passsage of a calculi through the ureters. 

EXPRESSION. 

In disease of the heart, and in urgent dyspnoea, acute laryngitis, the face is 
remarkably anxious and contracted. 

When there is much pain, especially in a vital org^an, the face is pinched and 
contracted. 

Immobility, most remarkable in catalepsy, or in states of unconsciousness, 
• and perhaps under the influence of spasms, and in tetanus. 

In nervousness and hysteria tiie opposite state exists. 

By the swelling of oedema or erysipelas, the expression of the countenance is 
materially altered. 

THE URINE. 

No product is so variable as the urine, both in health and disease. The kid- 
neys, being designed for great and immediate common purposes in the animal 
economy, in depurating the blood, or in transiently fulfilling the office of the 
skin, etc., are rendered highly sensitive to the presence of redundance in the 
blood, and to the variable states of other parts, especially of the skin, whose 
analogous office is so liable to interruption. The same Great Intelligence which 
ordained these final causes, also endowed the kidneys with a stability of function 
unknown to other parts, (excepting the heart, for a like principle,) where irrita- 
bility is easily impressed. 

Being therefore but little subject to actual disease, the variable product of the 
kidneys commonly supplies only a report of the nature of the ingesta, or of the 
influences which the skin or other parts, and even the mind, may exert upon 
these organs in a healthy state, or of the mutable state of the body in regard to 
nutrition, or of any disturbing reflex influences short of disease whith may be 



84 Principles and Practice of 

extended to the kidneys by diseases of other parts. It is thence obvious, that 
but little dependence in a general sense, can be placed upon the sensible changes 
of the urine as indicative of the nature or force of disease ; and I have endeav- 
ored to show, here and elsewhere, that we may rarely trust to chemical analysis 
of this product. Beyond a transient inspection, occasional evaporation is about 
all that we require, unless, also, some practical test in calculous affections. The 
aspects of the urine become more important in renal diseases and in those of the 
bladder. 

Albuminous urine appears in organic affections of the kidneys, in dropsy and 
after pastry and other indigestible food, and is produced by mercury and cathar- 
ides. It is evident, therefore, that the presence of albumen, about which so 
much has been written, indicates nothing specifically, unless supported by some 
other symptoms. 

A sensation like that of strangury is often felt when the urine is high colored 
and scanty. This is commonly owing to abdominal disease, particularly hepatic 
congestion. The following are the general characteristics of the urine in various 
diseases in which it serves as a means of diagnosis : 

In hysteria, remarkably pale, limpid and abundant, but not persistently so. 
Low specific gravity, often as low as 8 and 10. 

In febrile states, generally dark colored, with or without deposit, on standing. 
When the watery portion is deficient and much acid is secreted, there is a co- 
pious deposit on cooling. 

In disordered liver, it gives red stain to the vessel in connection with the fore- 
going states. 

In jaundice, presence of bile gives it a dark porter color. 

From altered blood, has a smoky color when acid, a pinkish hue when alka- 
line, quite crimson when much blood is passed. 

Urine, very highly colored, depositing a copious brick-dust sediment, being an 
excess of uric acid, present in all inflammatory affections except nervous, due to 
a rapid waste of fibrous tissue. 

We have this condition in its greatest extent or intensity in inflammatory rheu- 
matism. Urine, when depositing a white sediment, flaky or gritty, is indicative 
of an alkaline diathesis, and is always present in diseases of the nervous system. 

ALVINE DISCHARGES. 

Alvine discharges. The faeces consist of the superfluities of food, and the re- 
mains of various secreted products, which are poured into the intestine from the 
iver, salivary and pancreatic glands and mucous tissue. But neither the bile 
nor saliva, nor intestinal mucus, nor the gastric juice, appear in the faeces in their 
natural state. Combined, however, with the fasces, they offer a general natural 
standard for comparison with the morbid conditions. 

In disease the foregoing natural conditions as to quantity and quality of the 
secretions, and the state of the residual food, are more or less affected, according 
o the nature of the morbid states which may attend the various parts concerned 
\n digestion. 

From the number of organs, therefore, that are liable to be simultaneously in- 



American Medicine and Surgery. 85 

volved in morbid processes, and which contribute their fluids to thealvine dejer_ 
tions, as well as the imperfect changes which the food undergoes in the stomach 
it would seem more difficult than it is in reality to derive any just conclusions as to 
the nature of disease from the condition of the faeces. 

The following are the most important signs to be noticed in the alvine dis- 
charges : 

1st. The residual food. This gives us intelligence as to the state of the 
stomach. It is mainly important in chronic affections of that organ, t>r during 
convalescence from acute disease ; since, till the subsidence of acute diseases t 
the food should consist mostly of fluids whether the stomach be the direct seat 
of the affection, or disturbed by reflex nervous actions, or liable to irritation 
from solid food in the absence of those conditions. We may be thus guided, 
also, as to the food which should be avoided. 

2d. The nature and quantity of the matter discharged. This, in acute 
diseases, will consist principally, of the secreted fluids, which, so far as pro- 
duced, may cease to be in any way appropriated and accumulate in the intes- 
tines, though much, in respect to the apparent accumulation, may be due to the 
absence of residual food with which the secreted products are habitually 
intermixed. 

Their deficiency during the operation of a cathartic denotes severe disease in 
the organs of digestion, especially the glandular, or that an unsuitable cathartic 
has been applied. If the evacuation be large, watery and colorless the 
cathartic was bad. It has irritated, morbidly, the intestinal mucous tissue, has 
not reached the glandular function of the liver or may have propagated inju- 
rious influences upon that organ. 

If a judicious cathartic has been employed, and not in excess, and mucus 
alone follows, it shows inflammation of the intestinal mucous tissue, and 
disordered action, probably congestion, of the liver, which will be aggravated 
by a repetition of cathartics till the disease be lessened by other remedies, 
or delay of all remedies may be sufficient. Again, a redundancy of bile may 
be either unfavorable or favorable, and its proper interpretation may depend 
upon a variety of considerations ; such as color, the period and past history of 
the disease, the general and local vital signs, the nature of the remedies, 
especially of the cathartic employed, etc. 

When the bile is redundant, the mucus is apt to be, at least, natural in 
quantity, and when the latter is in excess the bile is commonly deficient, since, 
in the latter case, the formation of bile is diminished by morbific reflex nervous 
actions propagated upon the liver by the mucous tissue. It is the same as 
when morbidly irritating cathartics diminish or stop the secretion of bile. And 
here I will say that I am far from meaning alone what are denominated the 
drastic cathartics ; since calomel, blue pill, and even the neutral salts, may be 
more morbific in a given state of disease than scammony, colocynth, aloes and 
especially jalap, in doses of corresponding energy. In our practice, however, 
we do not resort to these irritating agents, active cathartics being seldom indi- 
cated in assisting the natural effort to throw off morbid accumulation. 

When the secreted products increase after having sustained a diminution, the 



86 Principles and Practice of 

sign is, perhaps, always favorable ; but how far so will depend upon other 
symptoms, and upon the amount which is due to nature. In some hepatic 
congestions cathartics procure but small evacuations till the disease is consid- 
erably overcome. The secretions then start, become abundant, long continued 
and a salutary bilious diarrhoea sometimes sets in. The same is also true of 
jaundice, whether arising from disease of the liver or from obstructions by 
gall-stones. 

3d. The appearance of the fecal matter as to color. This is a very impor- 
tant index in many respects. We should distinguish carefully, however, what 
may be owing to color of food, or what may be imparted by medicine, from that 
which is morbid. If the discharge be light it shows a suspended secretion of 
bile, which may be owing to the irritation of an improper cathartic, or to in- 
flammation of the intestinal mucous tissue, or to inflammation or congestion of 
the liver, or to jaundice, etc., and the other symptoms will clear up our knowl- 
edge upon the subject. In allthsse cases, as disease gives way, the bile is se- 
creted in redundance, is apt, at first, to be blackish, or of a deep green, then 
changing to brown, or to a dark yellow, till it finally becomes of a lightish yel- 
low. The worst appearance of the bile, per se, whether vomited or dejected, is 
a bluish color. It shows severe and obstinate congestion of the liver. Bloody 
mucus denotes more intense inflammation of the intestinal mucous tissue than 
a redundancy of simple mucus. It shows dysentery if attended with pain and 
tenesmus. Hemorrhage from the bowels or stomach denotes venous conges- 
tion and inflammation of the mucous tissue in .most cases ; though now and 
then in congestive fevers the hemorrhage comes from the liver. In all these 
cases it is an effort of nature to relieve a very formidable condition of disease. 

4th. Of the sensations produced by the fecal discharge on passing the anus : 
These are mostly of a burning or excoriating nature, and denote either the 
presence of a/norbid condition of the bile, or of acids that are generated by 
the decomposition of food. The suffering, however, generally arises from an 
acrimony of the bile. Aloes will, doubtless, produce irritation of the anus in 
some degree ; but when consequent on the use of that medicine it arises mostly 
from the bile which alone it is particularly instrumental in eliciting from the liver, 
while its sympathetic irritation of that organ will also increase the morbid acridity 
of the bile. The fact is particularly important, as will be readily seen from its 
bearings upon our conceptions of disease, and of the virtues of remedial agents. 

From what has been now said, it is evident that the dejections should be al- 
ways examined in all diseases of any severity and obstinacy, and, if produced 
by a cathartic, they should be all examined, and each one in the order in which 
it may take place. This is the only way of practicing medicine intelligently. 

The evacuations often supply more information as to the state of the abdom- 
inal viscera than all other symptoms. I say, therefore, when cathartics operate, 
it is often important to examine the dejections in the order in which they may 
take place. The first may consist only of the fasces resulting from food, and of 
secretions which had not assumed a morbid aspect With this partial inquiry, 
as is often the case, we may conclude that all is right with the abdominal viscera, 
or that they are in a state to bear any active remedies we may choose to ex- 



American Medicine and Surgery. '87 

"hibit for other purposes. But, on inspecting the second dejection, we may find 
it like chopped grass, or of a black, pitchy aspect. 

This brings us to the conclusion that mischief prevails at the fountain of life. 
What was evacuated at this second discharge was perhaps nearly the whole 
contents of the intestinal canal .; and what may be evacuated at the third, or 
'fourth, or farther dejections, will have been secreted after each successive evac- 
uation. 

If any salutary changes, then, be exerted by the continued operation of ca- 
thartics, we shall be likely to discover them in the color and other appearances 
of the discharges, as they come away, one after the other. If they remain with- 
out change more work is to be done. 

It appears, therefore, that modifications of mucus, wheresoever it occurs, and 
of the component parts of the alvine discharges, are essentially different from 
the morbid phenomena attending the pulse, the tongue and the urine, as indica- 
tive of the nature and force of disease. The first being the direct results of 
organs morbidly affected are critically significant of the pathological conditions. 
The last three, when the organs are not the seats of absolute disease, are indi- 
rect media which denote the intensity and modifications of the nervous influence 
that may be reflected upon the organs by disease of the other parts. In our 
ordinary investigations of symptoms, therefore, which relate to the tongue, the 
circulatory organs, and the kidneys, we are employed, however unconsciously, 
in estimating the relative conditions of reflected nervous influence, and by which 
we judge of the nature of the pathological conditions in which these influences 
originate ; although, in respect to the tongue, its morbid phenomena may be 
•more or less owing to continuous sympathy in affections of the alimentary mu- 
cous tissue. 

The following synopsis will serve to guide us in making up a diagnosis from 
•the stools, other indications corroborating : 

CHARACTER OF THE STOOLS. 

Simply watery, characteristic of diarrhcea. 

Undigested food observed, when functions are impaired. 

Fasces solid, condition of constipation. 

In fever, ochrey color. 

In cholera, resemble rice-water. 

In acute dysentery, scybhalous lumps, with blood or mucous pus serum, 
'product of inflammation. 

In chronic dysentery, muco-purulent discharges. 

When an internal abscess discharges, per intestinal canal, pure pus. 

When blood is mixed with the injesta, in stomach or upper part of the canal, 
black and pitchy coffee grounds. 

In hemorrhoids or hemorrhage, lower down in canal, more or less mixed with 
••blood of a more natural color. 

In deficiency of bile, clay colored. 

When fermentation supplants digestion, frothy and yeasty. 

. Form of faeces altered by a stricture of the rectum. 



SS Principles and Practice of 

i 

Prostrate gland being enlarged, fasces flattened. 

Hepatic and pancreatic diseases, fat in stool, of chopped spinach stools, irri- 
tation of the brain. 

FREQUENCY OF" THE RESPIRATION. 

This, in health, amounts to 14-18 per minute in adult men, to a somewhat 
larger number in women and children, and to 40 or more in the new-born. A 
normal pulse divided by four gives you the number of healthy respirations per 
minute, provided there is no disease of the heart, lungs,- brain. Position has 
but little influence on the frequency of the respiration, though it is rather faster 
when sitting or standing than when lying. The most extensive control is exer- 
cised over it by the will — it may be voluntarily deepened or made superficial, 
accelerated or retarded, or even arrested for 30-60 seconds. It goes on most 
quietly and regularly when Will and Perception are in abeyance, as in 
sleep. 

Of the deviations from the normal frequency acceleration is more common 
than retardation. The rate may increase to 7o ; 80 or even to over 100 per min- 
ute ; generally, however, it rises no higher than 40, Abnormal rapidity of res- 
piration is called dyspnoea. Respiration is sometimes not merely quickened,, 
but each inspiration may gain considerably in depth ; at other times respiration 
is simply fuller, while its speed is scarcely increased, or may even be diminished. 
The latter condition also is known as dyspnoea. Stertorous breathing with 
coma, inflammation of the brain, apoplexy and congestive fevers such as typhus- 
Respirations imperceptible in collapse, most frequent in fevers and inflamma>- 
tions generally. 

Most embarrassed in spasm of the cardiac and bronchii. 

Hurried or excited respiration in hysteria or nervous irritation.. 

TEMPERATURE OF THE BODY. 

The symptoms furnished by animal heat are various. The. temperature of 
the human body may be increased ; this may be general or local. In idiopathic 
and sympathetic fever there is general heat of the surface. 

In external local inflammation there is always at least the sensation of heat ;. 
and the skin of the forehead is often hot in cephalalgia ; the scalp in cerebral 
disease, the integuments of the chest in thoracic inflammations ; the hands and 
feet in phthisis, etc. Heat may be permanent or transient. There are differ- 
ent varieties of heat. The acrid heat of typhus fever, giving to the hand a 
peculiar burning sensation, increased by prolonged contact, is called cotor mor 
dax. Diminution of heat or cold presents the same varieties in relation to its 
intensity, seat, type and peculiar character. 

Coldness is a simple sensation of cold ; horripilation is accompanied with 
contraction of the skin and bristling of the hairs over the surface ; a rigor is 
attended with involuntary tremor. A chill of more or less intensity occurs 
as an initial symptom of febrile affections, and of the phlegimasias, particularly 
pneumonia. In cyanosis the temperature of the body is generally low, and 
this symptom is very common when the circulation, from whatever cause, is. 



American Medicine and. Surgery. 89 

languid. Nervous and anaemic persons suffer from coldnesss of the hands and 
feet. That the maintenance of animal temperature is a function of the nervous 
system, properly so called, appears from a variety of facts generally known, the 
temperature either of a part or of the whole body being lessened by any cause 
that impairs the action of particular nerves in the former instance, or of the 
whole nervous system in the latter. 

Normal temperature, 98 deg., adult life, slightly increased in children and di- 
minished in old age. 

An increase of heat over 98 deg. indicates diminished vitality. 

99 deg. to 100, phthisis pulmonalis ; from ioo to 103 deg., a condition of in- 
flammation or fever, favorable. From 103 deg. to 105 deg. and upward, de- 
cidedly unfavorable. 

A diminution of temperature is remarkably diminished in emphysema, atrophy 
of heart, cholera, collapse, etc. 



90 Principles and Practice of 



PROGNOSIS 

— OR — 

FOREKNOWLEDGE OF RESULTS OF DISEASE. 



Prognosis is that knowledge by which we are enabled to foresee the course, du- 
ration and event of a disease. Like the treatment of disease, it may be either 
empirical or rational. 

Empirical prognosis is that which is founded on experience or observation 
only, without regard to the nature of the disease or the reasons which deter- 
mine the results. It consists in the observation of the good and bad symptoms 
— that is, those symptoms which have, in a great majority of cases, been fol- 
lowed respectively by a good or bad result. 

This mode of prognosticating the events of disease was the only one attain- 
able in the early ages of medicine. The "prognostics" of Hippocrates chiefly 
consisted in the enumeration of good and bad signs ; and the frequent truth of 
the distinctions which he has made on these points shows the extent and accu- 
racy of his observation, or of the sources from which his information was 
drawn. 

In a limited sense the same faculty of empirical prognosis is often acquired 
by nurses or other non-medical attendants of the sick. These can often tell 
when a patient is getting better or worse by the appearance of the counten- 
ance, the state of the voice, the mind, the strength, the breathing, the exertions, 
etc., whilst they may be in total ignorance of the nature of the disease and 
why the signs are good or bad. This kind of prognostic knowledge, although 
it may be useful in enabling a person to pronounce a patient better or worse, 
falls far short of that which ought to be expected of the scientific practitioner, 
who should not only have a greater number of prognostic symptoms within his 
reach, but should be able to foresee them, so as to anticipate, and, if possible 
to influence them in a favorable manner. 

Rational prognosis is the estimation of the importance and tendencies of a 
disease from a knowledge of its causes, its true nature and symptoms, and of 
the power of treatment in regard to it. 

Like rational diagnosis, it derives its evidence from all available sources, and 
makes the best use of this evidence by analyzing it and thus determining its 
value. 

Thus in the early stage of inflammation of the lung, the discovery of the nature 
and seat of the affection at once shows the presence of a serious disease, what- 
ever may be the state of the present symptoms. 



American Medicine and Surgery. 91 

The practitioner, in forming a rational prognosis, takes into account the ex- 
tent of the inflammation, knowing, from experience as well as from reason, that 
this is a source of danger ; he considers the duration of the attack, and from the 
signs and symptoms judges whether it is increasing or not. 

These considerations may give him some insight into the severity of the dis- 
ease, but his prognosis is to be determined by further conditions. He knows 
by experience and reason that inflammation of the lungs, although always a dan- 
gerous disease, becomes much less so when it is at a stage and in a subject in 
which a combination of stimulants, diaphoretics, expectorants and proper local 
stimulation can be well borne ; thus, at an early stnge, in a young and vigorous 
subject, even the most extensive inflammations may be cured by counter-irrita- 
tion and other means judiciously employed, but if the disease has advanced far, 
and the functions of respiration have been for some days impaired by it ; if the 
subject he feeble from infancy, or from extreme age, or from some previous 
disease, from intemperate habits, from a complicating disorder, or from any 
other cause, the prognosis becomes more unfavorable, inasmuch as there is 
little power in the system to bear the appropriate remedies, or to withstand the 
evil effects of the disease. 

To take an example of another disease. In continued fever, certain symp- 
toms have been found by experience to be of an unfavorable character. The 
pathological practitioner profits by this experience, but he analyzes the results 
and goes farther. He knows that the appearance of petechias, congested face, 
and stupor at the commencement of fever, are bad symptoms, but that they are 
so, mainly in proportion as they arise from the changed state of the blood in- 
duced by the depressing cause of the fever, and when, as it sometimes happens, 
these symptoms appear without any corresponding depression of the heart's 
power, as manifest by extreme frequency and weakness of the pulse, they are 
by no means of such unfavorable import, but may arise from the plethora of 
the subject. Again, symptoms referable to the excito-motory system — such as 
subsultus, hiccup, and convulsive affections — are generally unfavorable in con- 
tinued fever ; but they are so only when arising from the severe operation of the 
cause of the fever on the nervous centers ; they are much less so when occur- 
ring in a nervous subject, in whom slight causes may induce them. The same 
remark may be made of a state of stupor, which would be of most serious im- 
port if dependent on fever alone, but it may be induced by slight fever or other 
cause in an hysterical subject. The pathologist is prepared for these differences 
and can qualify his prognosis accordingly. He can trace the danger of bad 
symptoms beyond the symptoms themselves, to those interferences with vital 
functions which render these symptoms dangerous, and of which these symp- 
toms are not always the true exponents. As our limits do not admit of details, 
it must suffice to enumerate the chief circumstances from which a rational prog- 
nosis may be formed with illustrative examples. These may be arranged under 
two general heads: — 1st. Those relaiing to the patient or subject, and 2d, those 
referring to the disease. 

The age of the subject. — Acute diseases are ill borne at either extreme of ; ge 
when the powers of reaction are less energetic to sustain the struggle. Hence 



92 Principles and Practice of 

infants and aged persons are often carried off by acute attacks. Acute diseases 
prevail more in young and middle age than in advanced life, in which affections 
tend to assume a chronic form ; also, from want of tnat power of reaction and 
resistance by which, in more vigorous age, morbid actions are thrown off. In 
early infancy there is always hope even with the most dangerous symptoms. 
"Infancy is the age of resurrection," says Chomel. It is at this period of life that 
the well-known adage, ubi vita, ibi spes, is so applicable. In old age, on the 
contrary, acute diseases, which assume a severe form, almost always terminate 
fatally. In middle age, the chances are more favorable and are greatest in 
youth and adolescence. The exceptions to this rule are the eruptive fevers, 
which are less dangerous in infancy, and certain organic affections, which are 
said to advance less rapidly in old age. 

The sex of the patient. — Nervous diseases are most common and obstinate 
in the female sex, but they are more serious in the male sex. The occurrence 
of the catamenia is often favorable, as their suppression is unfavorable in the 
course of the disease. Pregnancy and lactation, during their continuance, sus- 
pend or retard the progress of tuberculous disease, and other disorders of the 
nutrient function, and the cessation of these conditions may excite the disorders 
into fresh activity. 

Eruptive fevers, especially small-pox and scarlatina, are peculiarly fatal to 
women during and shortly after pregnancy. 

THE TEMPERAMENT OF THE PATIENT. 

In the sanguine temperament, disorders are apt to be acute or tending to a 
speedy termination, favorable or unfavorable ; in the phlegmatic temperament, 
more chronic and not uncommonly latent or obscure in their symptoms ; whilst in 
the nervous temperament the symptoms are very prominent, often exciting 
much suffering and alarm when little or no danger may exist, and they are like- 
wise remarkable for their mutability. 

PREVIOUS DISEASES OF THE PATIENT. 

The same disease having occurred before prevents or renders milder a sub- 
sequent attack, in the case of eruptive fevers, whooping-cough, etc., but in- 
creases the tendency and the danger in case of apoplexy and most structural 
diseases. Albuminuria with dropsy is more curable, when ensuing after scar- 
latina and gonorrhoea is often unusually severe and intractable. After contin- 
ued fevers, and other debilitating diseases, inflammations often assume a sub- 
acute or chronic form, which may escape attention and produce serious organic 
disease. 

PRESENT DISEASES OF THE PATIENT. 

These generally increase the severity or intractability of the new disorder, 
especially if they be structural. Thus infectious disorders and fevers are pe- 
culiarly fatal in persons with diseased heart, lungs, kidneys or brain. Yet mod- 
erate hypertrophy of the heart is rather a favorable circumstance in phthisis. 
Cutaneous and some other external diseases sometimes suspend attacks of the 
gout, gravel, diarrhoea, etc. Extensive emphysema of the lung supersedes tu- 



American Medicine and Surgery. 93 

bercles and most other lesions of the parenchyma, whilst it renders the bron- 
chial surface and liver the seat of almost constant congestion or inflammation. 
Cancer supersedes tuberculous disease, and reduces the proneness of the 
subject to inflammation. 

PREVIOUS HABITS OF THE PATIENT, 

Habitual intemperance, and excesses of all kinds, enhance the danger of all 
serious attacks and accidents. Extreme privations or over-fatiguing employ- 
ments make people liable to fevers and other depressing diseases, and reduce 
the powers of reaction against them, and the same remark will apply to close 
confinement and want of sleep. 

CONDITION OF THE PATIENT AT THE TIME OF ATTACK. 

Extreme weakness or exhaustion from any cause renders persons bad subjects 
for most diseases. 

Plethora increases the intensity of inflammatory affections. Simultaneous 
excitement of any organ, as of the brain from morai causes, may add a dan- 
gerous complication to continued fever. 

THE CAUSE OF THE DISEASE. 

Epidemic, endemic and infectious disorders are chiefly serious in proportion 
to the intensity of the cause. Thus the endemic of a hot climate is more dan- 
gerous than that of a cold climate ; an infectious disorder is more severe from 
the concentration of its cause and co-operating influences, than one arising 
from more diluted and simple infection. By knowing the source of the disease, 
some estimate may be formed of its future severity. 

THE SITUATION AND NATURE OF THE DISEASE. 

The more important to life is the part attacked, and the more the disease in- 
terferes with its functions, the more dangerous willit be. Thus the heart, the 
lungs, the medulla of the nervous system, the kidneys and the blood, cannot be 
extensively attacked without great danger to life, and if the disease goes on to 
affect structure, as in inflammation, the danger is prolonged in proportion. In 
a few cases disease attacking an unimportant part, as the skin or an extremity, 
may prove dangerous on account of its tendency to spread to other parts, or 
infect the whole frame, as in cancer, gangrene, inoculated poisons, hydro- 
phobia, etc. 

THE EXTENT AND PROGRESS OF THE DISEASE. 

The greater the extent of the disease, the more serious it will be in case of 
inflammation ; but the severity of the symptoms is often not in proportion to 
its extent, intense and circumscribed inflammation causing more prominent 
symptoms than that which is extensive and diffused. The rate of the progress 
of disease most materially influences its effect on life and health. Thus the 
structure of the lungs, heart, kidneys or liver may become diseased to an ex- 
traordinary amount, without destroying life, if the advance of the lesion is very 
gradual, whilst a third or fourth of the same mischief would prove fatal if it 
were induced suddenly. 



94 Principles and Practice of 

THE CHARACTER OF THE SYMPTOMS. 

This is exhibited in the details of each disease. Those symptoms augur fa- 
vorably which show a power of moderate and regular reaction, and a return of 
the functions to their natural state. The removal or alleviation of the more 
distressing symptoms of disease — the restoration of the natural appetites and 
feelings, bodily and mental— the retaining strength— the returning regularity 
and moderation of the pulse and other signs of equal circulation — the disposi- 
tion to sleep tranquilly and awake at the usual times-— secretions that have 
been interrupted or diminished being restored, and often in increased quantity, 
as if from accumulation, as in the case of critical perspirations, deposits in the 
urine, etc.— are among the chief signs of approaching recovery. 

Bad or unfavorable symptoms are those which arise from such an impedi- 
ment of one or more of the functions more immediately concerned in the sus- 
tenance of life, the circulation of the blood, respiration, nutrition and exertion. 
In proportion as these functions are speedily and considerably impaired, life is 
threatened, and there is an approach to its destruction by one or other of those 
terminations which are called modes of death. 

Thus there is death by syncope -cessation of the circulation, by asphyxia, or 
apnoea — interruption of the respiration, and by inanition. 

To these may be added death by the pernicious influence of excrementitious 
matters, and by poisons which cause death in various modes. 

These different modes of death are most distinct when induced so speedily as 
to leave the functions, which they do not directly affect, comparatively vigorous 
and outliving that which has been chiefly injured. 

Thus, in sudden death, from causes stopping the respiration, the heart con- 
tinues to act for some time, until the death which has begun with the breathing 
function reaches it also. If we further trace the operation of these different 
modes of death, we shall find that they all agree in affecting the blood, either by 
altering its composition or arresting its circulation ; and it is through one of 
these means that death extends to all the functions. Thus in death by cessa- 
tion of the heart's action the circulation is at once arrested ; hence, this is the 
most speedy mode of death. 

Inanition obviously operates by reducing the circulating material and by 
further weakening the organs by which the circulation is carried on. Asphyxia 
we have already found both to impede the circulation and to alter the condition 
of the blood. 

Excrementitious matter retained in the blood, and extraneous poisons, also 
operate in various ways : by impairing the irritability of the heart, or by injuring 
the medullary nervous function on which respiration depends ; or by arresting 
the passage of the blood through the capillaries ; or (and this probably includes 
some of the former modes) by so changing the properties of the blood itself as 
to render it unfit for its office of sustaining the activity of the functions ; and 
the operations of all poisons, as well as other causes of death, may thus be 
traced to defective circulation or composition of the blood. i 

It is the more necessary to keep these points in recollection, because they 
show why death from disease often takes place without distinctly beginning 



American Medicine and Surgery. 95 

with any set of functions ; but all fail from want of proper blood — their natural 
support. 

It will be useful to mention the chief varieties of the modes of death above 
noticed, and to state their symptoms which may become available as prognostic 
signs of the approach of death. 

Death {cessation of function) beginning at the heart — sudden — syncope, grad- 
ual — asthenia. 

Death, beginning at the breathing apparatus — asphyxia, or apncca ; begin- 
ning at the brain — conta\ beginning at the medulla — paralysis; beginning in 
the b\ood-^necrosmia. 

Death by cardiac syncope, or sudden cessation of the heart's action, may occur 
in two ways : 

First. By this muscle losing its irritability so that it ceases to contract. 

Second. By its being affected with tonic spasm, in which it remains rigidly 
contracted, losing its usual alternation of relaxation. 

In both these cases death is quite instantaneous, the subject suddenly turn- 
ing pale, falling back, or dropping down and expiring with one gasp. In the 
first case both sides of the heart are found, after death, distended with blood ; 
and if the examination were made soon after death the blood in the left cavities 
would be found to be florid. In the second case, the heart appears small and 
very hard ; the ventricles (or at least the left) are found so firmly contracted 
that the cavity is almost obliterated, and contains no blood ; the muscle is 
very firm ; but after masceration in water, or even without it, in two or three 
days, the wall of the ventricles yield to the pressure of the fingers and the cavi- 
ties may be restored to their normal dimensions. 

This state of the heart was long mistaken for concentric hypertrophy until 
Cruvilhier and Dr. G. Budd pointed out its true nature". 

Although syncope by loss of irritability (paralysis), and syncope by spasm, 
appear to be opposite states, yet they arise from somewhat similar causes. In 
animals wounds of the heart are followed sometimes, by the one, sometimes by 
the other. 

Death by shock, as from tearing off a limb, a violent blow on the epigastrium, 
crushing the brain or spinal marrow, is sometimes caused by spasm, although 
more frequently by paralysis of the heart. In sudden death from drinking a 
quantity of raw spirits, or of very cold water when the body is heated, the 
heart has been found contracted. 

Syncope by loss of irritability of the heart is the more common case ; and, 
besides, in the examples above given, it may be induced by the operation of 
large doses of certain poisons called sedative — such as the upas antier, infusion 
of tobacco, aconite, and digitalis ; and in combination with other effects, by 
large doses of hydrocyanic acid, strychnia, oxalic acid, arsenic, preparations of 
baryta, and various animal poisons. 

Mr. Blake found the power of the heart destroyed by solutions of various 
saline matters injected into the veins, especially salts of potass, magnesia, zinc, 
copper, lime baryta, and lead ; but these results do not correspond with what 
we find of the operation Of these substances when introduced into the stomach. 



§6 Principles and Practice of 

The diseases in which death by cardiac syncope sometimes takes place are: 
those of the heart, (but more rarely than is commonly supposed) hemorrhagic 
apoplexy, attended with much injury to the substance of the brain ; anaemia, 
and adynamic fevers. As it occurs suddenly there can scarcely be said to be 
symptoms ; but sometimes an approach to it has been manifested in previous 
attacks of common syncope or faintness. in which the action of the heart be- 
comes weak, irregular, and intermittent ; and the partial failure of the circula- 
tion is evinced in the paleness of the face, lips, and general surface, often with 
cold perspiration ; the failure of the sensorial functions, loss of consciousness 
and volition more or less complete, sometimes attended with various convulsive 
movements— the eyes turning up or becoming fixed or glazed, and the pupils 
dilated. The recovery from this faintness is often attended with shivering, 
vomiting, sighing, gasping, yawning, and various distressing sensations of noises 
in the head ; flashes in the eyes, palpitation, depression of spirits, etc., whilst 
the pulse regains its strength and regularity, and the color and warmth return 
to the surface. After this may ensue a reaction, like that which occurs after 
great losses of blood. 

Death by thzgradual cessation of the heart's action has been termed asthe- 
nia. This is the mode of termination of many diseases, especially those which 
destroy life by exhausting the strength, without any direct interference with the 
more vital functions* 

Thus long continued fevers, delirium tremens, gastritis enteritis, peritonitis, 
sometimes tetanus, hydrophobia, and inflammation of the brain, hemorrhages, 
and various discharges of animal fluids — such as diarrhoea, diabetes, extensive 
ulcers, or abscesses, etc., proving gradually fatal— inanition from want of food, 
and several others, reduce the power of the heart, and with it the functions of 
the whole body, to a lower and lower state, until at length the heart flutters and 
dies. 

The symptoms of the approach of death by asthenia are : increasing weakness 
of body and mind, whilst there may be no marked derangement of any particu- 
lar function of either ; increased frequency and diminished strength of the pulse ; 
the face, lips, and other parts of the surface gradually become paler and paler, 
or of a death-like sallowness ; the extremities lose their warmth, and often be- 
come oedematous ; the appetite fails ; the tongue becomes sometimes dry and 
brown, sometimes furred, and the mouth apthous ; the excretions first are im- 
perfectly voided ; then the sphincters lose their power, (the weakness reaching 
their excito-motory function) and involuntary discharges of urine and fasces may 
take place ; and this state of sinking in a few hours terminates in death. 

The symptoms above described are those of progressive loss of power, not 
confined to the heart, but through its failure, and that of the circulation of the 
blood, of which it is the chief instrument, becoming extended throughout the 
whole frame. 

But with this general debility there are often symptoms of partial excitement 
and reaction, which sometimes mark the sinking state. 

Thus a febrile excitement of a hectic kind may come on, giving slight tem- 
porary strength to the pulse, flush to the cheek, life to the eye, and a sort of 



American Medicine and Surgery. 97 

i 

flickering reanimation to the whole frame. Sometimes the excitement is more 
partial, affecting the brain as with delirium ; or the medulla, as with subsultus 
tendidum hiccough, or other slight convulsion ; or the stomach, as with vom- 
ting, etc. 

Or in the sinking state, some functions may become obscured before others, 
in consequence of congestions, effusions, or even low inflammations occurring 
in the capillaries of some organs, as the powers of general circulation fail ; thus 
the death by asthenia may become somewhat complicated with coma from con- 
gestion or effusion within the head ; or with dyspnoea from congestion in the 
lungs ; or somewhat similar symptoms may arise from the early failure of the 
excreting organs, and the retention of the excrementitious matter in the blood. 

Asphyxia, or apncea, has already been noticed as an element of disease, and 
its nature and symptoms were then examined ; we here advert to it as another 
mode of death. 

By death beginning at the breathing apparatus. I mean that in which the 
function of this apparatus is the first to fail. In this respect it is distinguished 
from death beginning at the brain, or medulla, which destroys by secondarily 
suspending the function of breathing, and the distinction is useful for practical 
purposes as serving to direct attention to the most suffering organ. Death by 
simple apncea takes place in diseases of the lungs and air-tubes, in which the 
entrance of air to the lungs is impeded by effusion into the air cells or tubes ; 
or by pressure upon them, as in bronchitis, pneumonia, pleurisy, etc., by ob- 
struction to the passage of air through the trachea or larynx, as in croup, laryn- 
gitis, and tumors or spasm constricting these tubes, or in circumstances mechan- 
ically excluding the passage of air by the mouth and nostrils, as in smothering, 
struggling, hanging and drowning. 

The symptoms of the approach of this mode of death are : increasing feeling 
of suffocation, or want of breath, which becomes most distressing and agonizing 
as the want is unappeased ; the efforts at respiration are made in a hurried and 
forced manner ; the face, neck, and other parts of the surface become congested 
in proportion to the violence of these efforts ; and as these efforts are unsuc- 
cessful, the color of the congested parts changes from red to purple, and from - 
purple to livid. The influence of this congestion and partial circulation of black 
blood is soon evident on the functions, causing stupor, reduction of tempera- 
ture, weak and irregular pulse, rapid reduction of muscular strength, and con- 
sequently of the efforts to breathe. Hence the dark hue of the face may be 
changed to paleness ; but the lividity of the lips, tongue, nails, and other colored, 
parts, remain until death. In cases of speedy death from violence, as hanging, 
drowning, etc, or from a sudden attack of laryngitis, or spasm, the respiratory 
efforts are more vigorous, and the congestion and lividity of the surface are- 
greater, and may remain until death. But in the slower asphyxia, from diseases 
of the lungs and air- tubes, the interruption to the breathing is less complete, . 
the efforts are less violent, the congestion of the surface is less marked, and the 
functions more gradually failing together, the symptoms peculiar to apncea are 
less decided. 

Hence, too, as imperfectly arterialized blood is circulated throughout the bcdy, 
7 



98 Principles and Practice of 

it may cause peculiar symptoms, such as stupor and low delirium, partia' 
paralysis, vomiting, relaxation of the sphincters, and other symptoms of sinking. 

This exemplifies what has been before remarked, that the distinctness of 
each mode of death generally depends on its speedy supervention. 

As prognostic signs, the symptoms of apnoea are more hopeless in proportion 
as they are conjoined with those of debility. The nature of the obstruction to 
the respiration must of necessity be taken into account ; and if this be not com- 
plete and irremovable, the congestion and lividity of the surface are not fatal 
signs, so long as the strength of the breathing apparatus and of the heart does 
not decline. As this becomes exhausted, the means of recovery are lost. 

Death by coma, or beginning at the brain, is caused by various influences 
which primarily destroy the functions of the superior masses of the nervous 
system. The chief of these circumstances are obstruction to the circulation 
through the brain by pressure, (as of effused blood, pus, lymph, or serum, or of 
distended vessels in apoplexy, a depressed portion of bone in fractured skull 
etc., by coagula within the vessels in anaemia, and by various narcotic poisons, 
such as opium, alcohol in large quantities, carbonic acid, or ether vapor inhaled, 
and sometimes the excrementitious matter of urine and of bile in the blood.) 

The symptoms of coma are those of interrupted function of the brain, insen- 
sibility and suspension of voluntary motion, the heart's action not being mate- 
rially impaired. These may come on in different modes. In apoplexy and in- 
juries of the head, they may supervene suddenly and the patient at once becomes 
powerless and senseless, the pulse continues pretty good, although slower and 
fuller than usual, or it may be frequent from mere sympathy. In other cases* 
the stupor comes on gradually and the senses and mental powers are often ir- 
regularly obscured, causing dimness of sight, appearances of clouds or cobwebs 
before the eyes, musc<z volitantes, various imperfections of hearing, with noises 
tinnitus aurium, numbness and tingling sensations in the limbs, loss of memory, 
confusion of ideas, hallucinations, low delirium alternated with stupor (typho- 
mania,) continued somnolency, etc. 

Partial paralysis often accompanies progressively advancing coma — sometimes 
of the lower extremities {paraplegia,) more commonly of one side, {hemiple. 
gia.) In the operation of narcotics, the state of coma is commonly preceded 
by symptoms of cerebral excitement, manifest in the usual signs of intoxication 
and delirium, which vary in the case of different poisons. For these particulars 
1 must refer to works on toxicology and materia medica. 

In conjunction with these symptoms, referable to the sensorial and voluntary 
functions, there are often symptoms of various affections of the excito-motory 
system of the medulla ; at first they are those of excitement, such as convul- 
sions, vomiting, hiccup, contracted pupil, etc, Thus, the coma of apoplexy and 
sometimes the stupor of narcotism are occasionally accompanied by convul- 
sions, general or local, and I shall elsewhere endeavor to explain ho'i*' these op- 
posite effects on different parts of the nervous centers may arise from the same 
cause. But in cases of more extreme coma, the excito-motory power of invol- 
untary motions becomes impaired, the breathing is stertorous and imperfect, 
the actions of coughing and expectoration are not easily excited, deglutition be- 



American Medicine and Surgery. 99 

comes impossible, the pupils are dilated, emetics fail to excite vomiting, the 
sphincters are relaxed and involuntary discharges of urine and fasces take place. 

It is a question whether the functions of the brain can become completely 
suspended for any length of time without those of the medulla suffering also. 
During common sleep there is not complete insensibility or suspension of voli- 
tion, for movements are then made in consequence of unpleasant sensations, yet 
without the sleep being broken. It is probable that in trance of nervous sub- 
jects, of hysteric coma, neither sensation nor volition is entirely abolished, but 
it is difficult to ascertain the truth in these cases, for the patients often deceive 
themselves as well as others. But in the heavy sleep of intoxication and in the 
stupor of coma, in which pinching scarcely excites any evidence of conscious- 
ness, the functions of the medulla seem to be also impaired, for the breathing is 
slow and stertorous, and irritations of the nose and eyes less readily than usual 
excite the motions of sneezing and winking. 

It is in proportion as these functions are impaired that coma becomes danger- 
ous, and it is because they are not impaired, (and in some instances are distinctly 
augmented as manifest by the sighing and spasmodic twitching that occur) in 
nervous or hysteric stupor, that this is unattended with danger. It appears prob- 
able, however, that coma, when complete, may cause death by the abolition of 
sensation only, and if so, we are warranted in distinguishing between death by 
coma and death by paralysis of the medulla. Although the movements of 
breathing are ordinarily independent of consciousness or will, yet such is not 
the case of the extraordinary movements which commonly take place in a deep 
breath or sighing, when the ordinary action is impeded by posture, fatigue, ex- 
haustion, or any other debilitating cause. 

Under these circumstances, when the function of the brain is unimpaired, the 
feeling of want of breath arouses a succession of voluntary efforts which are 
manifest in suspirious breathing, and which are the cause of sleeplessness in de- 
lirium tremens, and other states of exhaustion. But when sensibility and vol- 
untary power are wholly suspended, these supplementary efforts are not made ; 
for want of them, the respiration is insufficiently performed, and the lungs and 
air-tubes gradually become congested ; this congestion and the resulting se- 
cretion further impair the involuntary part of the process of respiration, and 
thus without any indications of paralysis of the medulla, the signs and effects 
of apnoea are slowly superinduced on the state of coma. 

Under such circumstances, it is of great importance to place the patient in 
such postures or other circumstances as shall most favor the movements of 
breathing and remove pulmonary congestion by the proper remedies, should it 
arise. 

Snoring arises from a relaxed state of the soft palate, and is of little moment 
so long as the movements of breathing are sufficiently strong and frequent ; but 
when the respiratory powers are impaired, stertor is not only a sign but a cause 
of obstruction to the passage of the air, and should be prevented as much as 
possible by changing the posture of the patient. 

The most dangerous kinds of coma, then, are those attended with symptoms 
of impaired excito-motory function, or those so profound and prolonged as to 



ico Principles and Practice of 

deprive the respiration of all aid from voluntary efforts, the signs of danger 
being apparent especially in connection with the respiration. In apoplexy, 
contraction of the pupil of one or both eyes is of very unfavorable import, 
because it indicates an excitement of the upper portion of the medulla, whilst 
the brain is oppressed ; such a combination can only proceed from the partial 
operation of a clot in the substance of nervous centers, compressing one part 
and irritating another. 

That death should ensue from injured function of the medulla oblongata 
and spinalis is quite intelligible, when it is considered that on this portion cf 
the nervous system the ordinary act of breathing depends. 

This mode of death, like the last, is by apnoea , but the death or failure of 
function here begins with the nervous link of the chain of actions constituting 
the process of respiration ; whereas, in simple apncea, it commences with the 
mechanism of the breathing apparatus. This death may be called death by 
paralysis, and, as in other cases of paralysis of the excito-motory functions, it 
may be caused by suspended function, either of the nervous center {medulla ob- 
longata) or of the different nerves (parvagum and sympathetic), or of the afferent 
nerves (phrenic, intercostals, and spinal accessory) which complete the respira- 
tory circle. 

Of influences which destroy the function of the medulla oblongata itself may 
be mentioned, hemorrhagic effusion into its substance or upon it, fractures of the 
base of the skull, and any very considerable pressure on the whole encephalon. 
I have witnessed several deaths from encephalic hemorrhage in which the 
stroke was not attended with loss of consciousness, and would not therefore 
be termed apoplectic, but paralytic, with loss of power of articulation, hemi- 
plegia and laborious and stertorous breathing, which was obviously aided by 
voluntary efforts or struggles, the patient, by gesticulations and viobnt gaspings, 
showing his consciousness of failing respiration. In two such cases, in addi- 
tion to some hemorrhage in one hemisphere of the brain, there was a clot in the 
pons varolii. 

These cases establish the truth of the distinction between the death by coma 
and death by paralysis. 

Some poisons also seem to affect the medulla more immediately than the 
brain. Thus, animals poisoned with essential oil of bitter almonds, conia, bel- 
ladonna, and perhaps some other poisons, are affected with gaspings and other 
signs of impaired functions of respiration before they lose consciousness ; ac- 
cording to the experiments of Sir B. Brodie and others, they die simply from 
suspension of respiration, and if this process be artificially maintained for a 
time, the animals may sometimes recover from the effects of the poison. The 
same remark, in some degree, applies to opium and its active principle, but less 
distinctly, for these early induce coma, and often impair the action of the heart 
also. Experiments are wanting to establish the elementary operation of this 
and other poisons as the functions are now viewed by physiologists. In some 
cases in which I have seen animals die from rapid hemorrhage, the respiration 
has ceased for some seconds before the heart's action, and from the peculiarly 
labored state of the breathing, and late retention of consciousness, I conclude 



American Medicine and Surgery. ioi 

that death from hemorrhage, in some instances at least, is due to suspension of 
the functions of the medulla. 

The division of the eighth nerves in the necks of animals illustrates one 
mode of inducing death by paralysis. These are the chief incident or afferent 
nerves from the lungs to the medulla, transmitting the impressions which ex- 
cite the motory nerves of the muscles of respiration. When they are divided 
the breathing is imperfectly performed, and expectoration and cough cannot take 
place ; apncea, therefore, gradually follows. Although we have not a result 
to the same amount exhibited in disease, yet we have an approach to it in the 
dyspnoea, sometimes constant, sometimes in paroxysms, caused by pressure of 
tumors on these nerves', or by malignant disease involving them. 

The third mode in which the nervous link of respiration may be broken by 
injury to the excito-motory column of the spinal marrow or its branches, is ex- 
emplified in the case of breaking the neck, or dislocation of the upper cervical 
vertebras. 

Pithing an animal effects the same thing. All parts supplied by nerves 
from below the injured portion of the medulla become paralyzed, and therefore 
their motions cease. 

Disease in the vertebra?, in the spinal cord, or in its membranes, have been 
followed by similar results ; and the functions of the several nerves of respira- 
tion are illustrated by these cases. I have known disease affecting at the upper 
cervical vertebrae cause less of motion in all parts below the neck except the dia- 
phragm, which is supplied by the phrenic nerve, and through which for awhile 
respiration was wholly carried on. The patient afterward gained power in the 
spinal accessory nerve, by which he was enabled to elevate the upper part of the 
chest and subsequently some power was for a time restored to the superior in- 
tercostal nerves and muscles. In other cases diseases of the spinal cord creep 
from below upwards, beginning with paralysis of the lower extremities and pelvis, 
then reaching the dorsal spine paralyzing the intercostals and at last reach- 
ing the neck. 

The advance or retrogression of all these symptoms are of great importance 
in the progress of such diseases. Besides the respiratory functions, the func- 
tions connected with excretion are dependent on the integrity of the spinal cord; 
they fail when it is seriously injured, and this failure may furnish symptoms of 
death- beginning at the spinal cord. When the cord is injured only at a point, 
and remaining healthy above and below it, the injury may merely intercept the 
transmission of sensation upwards, or of volition downward beyond the injured 
point. Hence, there may be loss of sensation, or of voluntary motion, or of 
both, in the lower portions of the body. If this reach the urinary apparatus, the 
power of spontaneously urinating is lost. But the reflex or independent excito- 
motory influence of the spinal cord remains, hence the sphincters and the blad- 
der retain their power, and when the catheter is introduced into the bladder, it 
contracts as usual, aided by the voluntary power remaining in the diaphragm 
and abdominal muscles. We have before noticed, that under these circumstan- 
ces the muscles of the lower extremities retain and accumulate their irritability, 
and akhough the will has no command over them yet tickling, or even touching 



102 Principles and Practice of 

them, may excite them to contract with unwonted energy. The exercise thus 
kept up seems to be sufficient to preserve their nutrition, for they do not waste 
away. 

But it is quite different if the spinal cord be extensively injured as by crush- 
ing, softening, or a considerable effusion of blood or pus into its sheath. Its 
function then ceases, not only as a communicator of sensation and voluntary 
power to the lower parts of the body, but also as a source of that excito-motory 
power by which the sphincters contract and the urinary bladder evacuates its 
contents. Hence there is constant dribbling of urine, yet without the power 
completely to empty the bladder. The faeces are discharged unconsciously, and 
without the power of control. 

The limbs are not only insensible and powerless to the will, but their muscles 
can no longer be excited by tickling ; they loose all motion and the blood- ves- 
sels lose that influence which the nerves of all orders exercise upon them. It is 
not surprising, under such circumstances, that the death which has begun in 
the spinal cord should spread to the. parts whose functions it can no longer 
maintain. 

The urine, imperfectly discharged, putrifies, and causes inflammation of the 
bladder which may gradually extend to and stop the functions of the kidneys. 

The intestines become distended and obstructed with gas and pent-up faeces. 
The limbs loose their proper circulation for want of motion, and nervous influ- 
ence in their muscles and vessels, their nutrition fails, they become cedematous, 
partially inflamed, livid, and run into gangrene, and all these changes are so 
many signs of the progress of death which has begun in the spinal cord. 

From the remarkable effect of cold and some poisons on some of the lower 
animals, inducing paralysis of the hinder extremities, it is probable that these 
agents are capable of especially injuring the function of the spinal cord, begin- 
ning with the remote part. Has the gangrene of the lower extremities, some- 
times induced by the use of ergotted corn, any connection with an injured func- 
tion of the spinal cord ? 

Death of the medulla supervenes on that, beginning with coma and asthenia 
in many cases ; and as its involuntary excito-motory function is the guardian 
of many processes essential to life, the symptoms connected with it are of great 
importance in connection with prognosis. 

NECR/EMIA, OR DEATH BEGINNING WITH THE BLOOD. 

are terms which I venture to give to those fatal cases in which the chief and 
most remarkable changes are exhibited by the blood. In typhoid fevers and 
others of the malignant or pestilential kind, none of the solids of the body 
constantly exhibit such an early change of function or of structure as would 
warrant us in tracing disease and death to them. It is true that the functions 
of many solids are impaired — the muscular and nervous systems, secretions, 
digestion, assimilation and nutrition, all suffer, but the very universality of the 
affection seefns itself to point to some cause more general than can be found 
in any individual function ; and such a cause may be found in the blood. 
The blood, at an early period of these diseases, when they occur in. their 



American Medicine and Surgery. 103 

worst form, exhibit changes which show that disorder begins with it, and this 
disorder may reach to a fatal degree. 

The appearance of petecheat, and vesicles on the external surface, the occur- 
rence of more extensive hemorrhages in internal parts, the general fluidity of 
the blood, and frequently its unusually dark or otherwise altered aspect, its poi- 
sonous properties as exhibited in its deleterious operation on other animals, and 
its proneness to pass into decomposition, point out the blood as the first seat of 
disorder, and by the failure of its natural properties and functions as the vivifier 
of all structure and function, it is plainly the medium by which death begins in 
the body. 

How far the change in the blood is in its structure and vital properties, or in 
its chemical composition, further research alone can determine ; the vivifying 
function of tlie blood depends on all these combined, and it is this function 
which obviously fails. Hence the complete adynamia or general prostration of 
all living powers, which occurs when this cause of death is most powerful. 

The blood, the natural source of life to the whole body, is itself dead and 
spreads death instead of life. 

Almost simultaneously the heart loses its power, the pulse becoming very 
weak, frequent and unsteady ; the vessels lose their tone, especially the capilla- 
ries of the most vascular organs, and congestion occurs to a great amount ; 
the brain becomes inactive, and stupor ensues ; the medulla is torpid and the 
powers of respiration and excretion are imperfect ; voluntary motion is almost 
suspended , secretions fail, molecular nutrition ceases and at a rate much more 
early than in other modes of death, molecular death follows close on somatic 
■death — that is, structures die and begin to run into decomposition as soon as 
the pulse and breath have ceased ; nay, a partial change of this kind may even 
precede the death of the whole body; and the foeted apthous patches in the 
throat, the offensive colliquative diarrhoea of persons in the last stages of vari- 
ous fatal diseases.; parts running into gangrene as in the carbuncle of plague, 
the sphacelous throat of malignant scarlatina, and the sloughy sores of the 
worst forms of typhus, and in the large intestines in dysentery, and the putrid 
odor exhaled even before death by the bodies of those who are the victims 
•of similar pestilential diseases — are so many proofs of the early triumph of 
dead over vital chemistry. 

We have hitherto represented an extreme case ; but there are many lower 
degrees in which disease begins with the blood, and various disturbances and 
reactions result The causes which appear thus primarily to affect the blood 
•are especially endemic, epidemic and infectious influences called poisons, cer- 
tain animal and vegetable poisons, as that of the most venomous reptiles and 
: fungi, and probably some mineral poisons, as sulphuretted hydrogen, selenium, 
and, in part of its operation, arsenic. The direct influence of all these agents 
is depressing, and when they operate in large quantities, or in a concentrated 
form, the vital powers fall quickly into a state of adynamia or prostration t 
which soon ends in death, as we have already described it, the blood first and 
most constantly manifesting a change. But if the noxious influence is in 
smaller quantity, or more diluted, the vital powers react against it in various 



104 Principles and Practice of 

ways, the object of which can often be plainly discovered to be its expulsion 
from the system. The shivering hot stage and sweating terminations of par- 
oxysms of intermittent fever, the similar but less marked sense of febrile move- 
ment which occur in slight forms of remittent and continued fevers ; the pro- 
fuse and violent fluxes of the stomach and intestines in cholera dysentery, and 
epidemic diarrhoea, and the similar discharges induced by poisonous ingesta» 
are instances of the operation of vital reaction attempting the expulsion of the 
noxious matter, and of that part of the animal fluids that had been corrupted 
by it. 

But these struggles, in many instances constitute serious diseases in which 
life may be compromised by the violent and exhausting effect of the reaction, as 
much as by the prostrating influence of the cause of the disease, in these more 
complex affections, individual organs may especially suffer in different cases and 
the danger and cause of death may be less in the changed condition of the blood 
than in the affections of particular organs, or the exhaustion consequent upon 
them, which destroy, not by necraemia, but by coma, asphixia, or asthenia, 
modes of death already considered. 

The injurious effect of these poisons may be still more completely prevented 
when their quantity is small and the living powers are vigorous. A diarrhoea, a 
profuse sweat or a free flow of urine sometimes carries off the commencing 
disease. The intestines, the skin, and the kidneys, appear to be the proper 
emunctories through which morbid matter is expelled. The peculiar fetor of 
the secretions from the bowels in typhoid fever, the beneficial influence of mod- 
erate diarrhoea, which removes them in the early stage of fever, and appearance 
of a foul, fibrinous matter, (typhus material of German writers,) in the intesti- 
nal glands, seem to be examples of the elimination of morbific matter. This 
was exemplified in the case of an epidemic erysipelatous angina which attacked 
several patients of the University College Hospital, London, in the spring of 1843. 
Out of about a dozen cases in which persons affected with various diseases were 
attacked three died from the erysipelas extending to the larynx, and in all 
these the kidneys were granular and the urine albuminous. 

The follicular inflammation, ulceration and sloughing of the intestines in fe- 
ver may arise from the excessive irritation of the follicles in the exercise of this 
eliminating function. Again, with regard to the kidneys' granular degeneration 
which impairs their function and power of elimination renders the body pecu- 
liarly liable to contract epidemic and infectious diseaseas and to succumb under 
them. This renders the prognosis unusually unfavorable in these cases. The 
same remark extends, and for the same reasons, to persons who have been ha- 
bitually intemperate. On the other hand those whose kidneys are naturally ac- 
tive more effectually resist disease, and more readily throw off its effects. In 
like ma§ner it is well known that persons with a naturally dry skin do not so 
readily get rid of a fever as those in whom perspiration is readily excited. Be- 
sides the influences already mentioned as first attacking the Wood and in ex- 
treme cases injuring its composition and causing its death, there are others orig- 
inating in the body itself. 

Thus the processes of gangrene and suppuration sometimes infect the blood 



American Medicine and Surgery. 105 

with a septic poison and cause death in a manner and with symptoms like those 
of the poisons above noticed. The sudden suppression of the excretions of 
urine or bile from disease, or under the influence of any severe shock, also seem 
in some cases to operate by injuring the properties of the blood, whilst in other 
instances it distinctly induces coma or asthenia. We have before adverted to 
retention of excrementitious matter as a cause of cachcemia or depraved state 
of the blood, so we now find that in an extreme degree it may cause necr<zmia 
or death of the blood. The symptoms which should make us apprehend the 
approach of death by necraemia, may be gathered from the preceding descrip- 
tions. Those symptoms generally called typhoid, putrid or malignant, belong 
especially to this class of deadly influences. For example : A congested appear- 
ance of the whole surface, the color being dusky or livid, and extending to the 
conjunctiva, tongue and fauces, various slight exanthematous or papular patches 
on the skin, often with petechiae, more extensive hemorrhages in form of ecchy- 
moses, or oozing of thin bloody fluid from the gums, nostrils and sometimes 
from other passages, extreme prostration of the strength, with an obtuse state 
of all the senses and mental faculties, somatimes combined with delirium and 
twitching of the limbs, half-elosed eyes and dilated pupils; a very frequent, 
weak and soft pulse ; frequent and unequal respiration, no appetite, intense 
thirst, a dry, brown tongue, with dark sordes on the lips and teeth ; a progress- 
ive fall of temperature, which may have been elevated at first ; often cold, 
clammy and fetid perspiration, hiccup, subsultus tendinum ; scanty, offensive 
urine, involuntary discharges. 
Some diseases of the same class are modified by peculiar effects : 
Thus, in malignant cholera, excessive discharges of serum, by vomiting and 
by stool, reduce the blood to such a spissitude, that it will no longer circulate 
through the vessels ; the pulse ceases and the surface becomes blue and cold 
from the darkness and stagnation of the blood, and shrunk from the exhaustion 
of its fluids. In yellow fever altered blood is ejected from the stomach in the 
form of what is called black vomit. But to pursue the subject into further de- 
tails belongs rather, to the department of special pathology. It has been before 
mentioned, that the complete distinction of these different modes of death, is 
almost exclusively confined to cases of speedy or sudden death. In the slower 
dissolution, by which diseases generally prove fatal, all functions and structures 
are more or less involved, and the life in all is dwindled down to a slight thread, 
so slight that where it breaks in one* others scarcely retain it long enough to en- 
able us to say that death begins distinctly in any part. A brief sketch of some 
of the most common symptoms influencing our prognosis, will not, perhaps f 
be here without value, much may be inferred from the general aspect of the 
patient. Constant change of the position, unimportant in the beginning of acute 
diseases, becomes alarming when it persists for any time. Lying continually in 
the §ame position, as constant dorsal decubitus, in low forms of disease, is a 
very bad symptom. 

Inability to lie down, which sometimes happens in thoracic disease, is equally 
sinister. Jactitation succeeding to quietude, in the latter stage of acute disor- 
ders, is generally a mortal sign, especially when accompanied by an attempt to 



106 Principles and Practice of 

throw aside the bed clothes, and ineffectual attempts to rise. Progressive ema- 
ciation in acute affection is of little importance, but in chronic disorders it 
should lead us to anticipate a fatal termination in proportion to its rapidity. 
General oedema is an extremely bad augury. 

The occurrence of sloughs in various parts of the body, in both chronic and 
acute disorders, is a very bad sign. The physiognomy should be especially 
studied in reference to prognosis. When the natural expression of the coun- 
tenance is preserved, it is always of favorable import. Great alteration in the 
features in the commencement of an acute disorder, ought to make us fear, 
about the fifth or ninth day, the supervention of low symptoms. 

In the advanced stage of all diseases, a sudden and great alteration in the 
physiognomy announces approaching dissolution. When it occurs at a period 
where a fatal termination is not to be anticipated, it should lead us to suspect 
the development of some acute affection, the enfeebled state of the patient not 
admitting of its exhibiting the ordinary local symptoms, a sudden aggravation 
of the general symptoms being the only indication. It generally announces 
death in less than three days. 

This change of countenance must not be confounded with the pallor which 
marks the commencement of convalescence in fever, etc. , the accompanying 
phenomena serve to distinguish them. Subsultus, trembling and rigidity always 
denote danger. Carphologia, epileptic and tetanic convulsions, rigidity of the 
limbs, are mortal signs in the advanced stages of fever. 

Another invariably fatal symptom, according to Chomel, is the automatic 
movement by which the patient seeks to approach his hand to his body while 
the physician is feeling his pulse. Aphonia is a bad sign in acute disorders. 

The intensity of pain by no means in general indicates the amount of dan- 
ger. Cceteris paribus. Deep seated pain is more unfavorable than that which 
is superficial ; and that which is fixed more so than that which is variable. The 
sudden cessation of pain in inflammation, joined to great alteration in the fea- 
tures, indicates approaching death. 

According to Chomel suppuration not gangrene will be found under such 
circumstances, on examination. Deafness is a sympathetic phenomenon occur- 
ring in many acute diseases, and is always serious. 

In the mortality of typhoid fever, if a comparison be made of those who 
suffered from deafness in the course of the disease and those who did not, the 
deaths among the former will be found as two to one among the latter. Hope 
and cheerfulness are generally good signs. 

Distrust and despair are very unfavorable symptoms. It is rarely that pa- 
tients who have the persuasion that they will die, recover, unless they are hypo- 
chondriacs. Total indifference is a bad sign. In several chronic disorders the 
tranquil security enjoyed by patients does not demonstrate the gravity of the 
prognosis. 

The prognostic signs furnished by delirium are connected with its intensity, 
persistence, and the conditions under which it occurs. Wild delirium soon pass- 
ing off is not serious, permanent delirium always is. Many persons, of all 
ages, are liable to delirium whenever they are attacked with ephemeral fever, 



American Medicine and Surgery. 107 

or an angina, it is only necessary to be aware of the idiosyncrasy in order to 
appreciate the value of the symptom. 

Prolonged sleep in the course of fever is not dangerous if the patient is read- 
ily aroused. Coma is alarming and nearly always mortal when intense and 
permanent. 

The sudden occurrence of a voracious appetite announces speedy death. 
Chomel has frequently met with this symptom in pneumonia, death soon took 
place. Dysphagia is generally a fatal symptom in cerebral and acute disorders. 
The signs which the respiration furnishes prognosis are important and rarely 
deceive. A hurried repiration indicates great danger. When the number of 
respirations amount to fifty in the minute, it may be generally stated that death 
will soon follow. The tracheal rattle and stertorious breathing are usually pre- 
cursors of dissolution, especially when they occur towards the latter stages of 
cerebral disease. 

In inflammation of the lungs stertor is not alarming so long as expectoration 
takes place. Paroxysmal is less dangerous than permanent dyspnoea. Hic- 
cough is a very unfavorable symptom in the latter stages of disease unless it is 
accompanied by a notable amendment in the other symptoms. 

A pulse of moderate frequency and force is favorable. Considerable fre- 
quency of pulse indicates something serious. A pulse of 150 in an adult should 
lead to a very unfavorable prognosis. If at an advanced period of any affec- 
tion the pulse becomes irregular or intermittent, or ceases, death is near. 

Augmentation of the heat of the body is of bad import, especially when 
dry. Sudden chilliness of the extremities and rest of the body occurs usually 
a short time previous to dissolution. 

Chills at an advanced period of the disease, should lead to the suspicion of 
the formation of pus, or of its resorption, according to circumstances. 

Abundant sweating towards the close of a disease is a favorable sign. Cold 
sweats at the same period are generally unfavorable. 

Hemorrhages at the beginning indicate usually that the disorder will be seri- 
ous. Towards the close they are either favorable or unfavorable. Epistaxis, 
the hemorrhoidal flux, and menorrhagia, are generally favorable signs in those 
who are liable to them. Hemorrhages from the lungs and intestines are usu- 
ally mortal, those from the urinary organs nearly constantly fatal. 

The degree of strength which the patient possesses is of great importance 
in forming a prognosis, considerable diminution or perversion is always dan- 
gerous, especially in the early stage of the disease. 



io8 Principles and Practice of 



PROPHYLACTICS AND HYGIENICS, 



Prophylactis is the guarding against a particular disease, and hygienics i elate 
to the prevention of diseases in general, or to the preservation of health. The 
former is connected with special rather than with general pathology, and it 
should be founded on a due knowledge of the causes, nature and tendencies of 
disease, and of the various means in diet, regimen, residence and medicine, which 
are capable of removing the causes of disease, or of preventing or counteracting 
their operation. Hygiene consist in the knowledge and application of those means 
by which the structure and hygienic functions of the body may be kept in that 
normal state which conduces to their continued welfare — that is in health. We 
have found that both structures and functions have the elements of disease in 
themselves, when any thing disturbs their due proportion. 

It will be sufficient in this place to consider briefly the chief corresponding 
circumstances which promote the maintenance of health, and these may be ar- 
ranged under the following heads : Food, Clothing, Temperature, Air, Exer- 
cise, Mental Occupation, Sleep, Excretion. The nature of this work precludes 
many details on these important topics, and the following is intended as a mere 
outline in conformity with the principles previously explained. 

The object of hygiene is the preservation of health and the prevention of 
disease, and hygienics include everything which tends to accomplish these 
ends. 

Although hygiene has been called the medicine of healthy individuals, it is 
still applicable and even indispensable to invalids, and is often of more service 
to them than medicine itself, for whilst the efficacy of many remedies may be 
doubtful, the propriety of hygienic measures is universally admitted. 

By their aid alone, without a resort to the materia medica, the majority of 
acute disorders will terminate favorably, without them our best directed efforts 
will often prove unavailing. We frequently see patients in bad hygienic condi- 
tions perish in spite of able physicians, and an abundance of remedies, and the 
mildest diseases converted into mortal ones from similar reasons. 

The crowding of patients into narrow, ill-ventilated places, the contamina- 
tion of the air, the absence of cleanliness, the want of suitable clothing, expo- 
sure to cold and wet, errors of diet, mental depression, fatigue, collectively in- 
variably produce terrible effects, whilst in a large number of acute affections of 
the severest kind, recovery occurs without a resort to any active remedy, merely 
under general hygienic measures. 

FOOD. 

The purpose of food being the supply of materials which, when prepared by 
the process of digestion, shall repair the waste of the body and maintain its 



American Medicine and Surgery. 109 

temperature, it is obvious that this purpose will be best fulfilled when the ma- 
terials supplied are of such quality and quantity and so administered as to suit 
respectively the powers of digestion and the wants of the system for nourish- 
ment and warmth, in other words food should be digestible, nutritious and 
califacient, and the articles which duly comprise all these qualities will be the 
most wholesome food. The importance of a due combination of the chief ali- 
mentary principles, albumen, oil, sugar or starch, with water as their diluent, 
has been before pointed out, and the expediency of preferring such materials 
as comprise these in the best quality or condition may also be inferred from 
preceding observations. It may not be superfluous to exemplify these points 
further by a few comments on common articles of diet. 

Wheaten bread comprehends the albuminous (gluten) and the amylaceous 
principle, and only needs the addition of butter to complete the requisite com- 
bination for moderate nutrition. The goodness of bread depends not only on 
the character of the grain from which the flour is obtained, but also on the 
mode and degree of its fermentation and baking. If fermented with leaven in- 
stead of yeast, or if even over fermented, acetic acid is generated and the bread 
is sour ; and this is the common fault of bread in large towns where the supply 
of yeast is insufficient. 

This evil is avoided in the unfermented bread which is rendered porous by 
an effervescence of carbonic acid gas, caused by an admixture of carbonate of 
soda with the flour, and hydrochloric acid with the water of which the bread 
is made ; where well prepared such bread is very sweet and free from acidity, 
but unless carefully prepared is liable to be heavy, and, like imperfectly fer- 
mented bread, is unfit for mastication. 

Bread insufficiently baked is glutinous and indigestible, and much of the same 
objection applies to quite new bread which has not dispersed its moisture. 
These defects may in a great measure be remedied by toasting the bread in 
thin slices, which has also the advantage of dispersing much of the acid from 
the sour bread. Very white bread is objectionable as being less nutritious 
(having less gluten) and more constipating than that made with less refined 
flour; but the coarse material commonly sold as Graham bread errs to an opposite 
extreme in containing a bran so coarse as to be irritating to many stomachs. 

Good country bread fermented with yeast, and well baked, presents the kind 
most generally wholesome. 

Meat comprises the albuminous, oily and gelatinous principles, besides crea- 
tine and other soluble extractive matters, which are probably nutritious. It 
requires combination with vegetables or bread to make it suitable to the palate 
and stomach. The object of keeping and cooking meat is to make it so tender 
as to be easily softened by the gastric juice and all processes which interfere 
with or go beyond this result, render meat less wholesome. Thus salting or 
pickling, keeping until it becomes tainted, or hardening it by over-cooking or 
fast boiling, which corrugates and toughens the fibre, are so many means of 
spoiling the meat for the purposes of digestion, aud rendering much of its nu- 
triment unavailable. The flesh of young adult animals presents the greatest 
amount of fibrinous nutriment ; that of younger animals contain more gelatine 



no Principles and Practice of 

and fat, and that of older age is tough from the prevalence of fibrous textures, 
which, being gelatinous, are more serviceable for soups. 

The kinds of animal food vary much in their composition, even when the lean 
parts only are selected. Thus beef and pork contain a large proportion of fat, 
mutton somewhat less, veal still less, and in the flesh of fowl, game and white 
fish there is only a small amount. This affords an explanation of the fact that 
the latter articles are the best suited to persons of weak stomachs. But the 
proportion of creatine and colored extractive, doubtless also determines the 
quality of the food ; thus the flesh of hare, which contains much, is more heating 
than that of chicken and whiting, or sole, which may be taken as the represen- 
tatives of the mildest form of solid animal nourishment. 

Soups and broths, when deprived of excess of fat, are very useful articles of 
auxiliary nourishment in combination with solid food, but they are not sub- 
stantial enough to supply a meal to a healthy person. 

Eggs and milk, respectively, separately or combined, form light and nutri- 
tious articles of animal diet. They are rendered easier of digestion by being 
heated to about 180 , by which part of the albumen is slightly coagulated. 

Both eggs and milk contain a considerable amount Of oil, which causes them, 
when taken too freely, to disagree with persons of bilious habit. So, likewise, 
they are prone to speedy decay, and lose much of their wholesome nature, even 
in a day or two. In like manner, fresh butter is an excellent adjunct to bread 
and vegetable articles, but speedily becomes rancid and loses its salubrious 
properties. Cheese is a low form of protein compound, which requires ener- 
getic digestive and assimilating powers to raise it to the higher standard of 
the material of the plasma of the blood ; it is therefore wholly unfit for delicate 
persons and those of weak digestion. Oleraceous and succulent vegetables 
and fruit are fit adjuncts to the more nutritious articles of food, which they 
serve to dilute ; and by the sub-acid and extractive matter which they contain 
they promote the secretions and thus tend to purify and cool the blood. In 
most instances they require to be thoroughly cooked to give them the state of 
softness fit for the digestive process. 

The choice of food and the arrangement of hours for different meals must 
vary much according to the habit and necessary occupations, as well as the 
strength and tastes of individuals, but the following plan of diet, with some 
variations, will be found well suited to the majority of healthy adults. 

Breakfast, at from 8 to 9 A. M„ of bread or dry toast, with a moderate quan- 
tity of butter. One or two new laid eggs, boiled three minutes and a half, or a 
little cold chicken or game, or even a mutton chop, may be, added for those who 
use much bodily exertion. Beverage, one breakfast cupful of clear strong in- 
fusion of coffee with scalded milk. Cocoa, deprived of fat, or thin chocolate, 
with milk, may be substituted. 

Dinner, at from 12 to 2 p. m. • Soup, wholesome fresh meat and vegetables, 
well but plainly cooked, served hot, carefully proportioned, properly masticated, 
varied from day to day with simple additions of fish, and moderate quantities 
of farinaceous or fruit puddings. 

Highly seasoned dishes, pickles, salted and dried meats, rich and heavy pas- 



American Medicine and Surgery, 1 1 1 

try, and cheese, except as a mere relish, ought to be excluded from a table pro- 
fessing wholesomeness. 

If water is taken it should be in moderation, otherwise it may interrupt diges- 
tion. Some find warm water, or milk and water a pleasant beverage. The 
habit of taking wine after dinner is one of luxury, not of health, and all that 
can be said of it in hygienic instructions, is — the less the better. 

The practice of taking a little fruit at the same time is not equally hurtful, 
provided, by its quality or quantity, it does not excite indigestion. 

Tea. The English custom of taking tea, or a simple warm liquid meal, three 
or four hours after dinner is a very salutary one, and probably disagrees only 
with those who dine too late or overload the stomach at dinner. The purpose of 
the warm liquid is to assist in the separation and absorption of the chyle from 
the chyme which takes place at this period, and it is obvious, that it would interfere 
with this process to introduce solid food into the stomach, therefore little or 
nothing should be eaten — certainly not quantities of buttered toast, rich cake, 
and the like. Two or three moderate cups of black tea with a little milk and 
sugar, forms a wash to the stomach to carry away the taste and smell of 
dinner, and remove all acrid materials, left by digestion, which might disturb 
that rest for which the hour now approaches. 

The practice of dining early, at from one to three p. m., which is pursued by 
the majority of persons in the lower and middle ranks of society, would de- 
serve more general adoption on the score of health, were it not generally im- 
possible then to devote the time to it, and to rest after it, that the principal meal 
requires. 

A hurried, early dinner, if enough to satisfy the appetite, is pretty sure to 
cause indigestion, and disqualifies for exertion afterwards. If, on the other 
hand, it be purposely made light, it may not suffice for the wants of the sys- 
tem, and an evening meal or supper will be necessary. The chief objection to 
suppers is, that they are indulged in either so freely or at so late an hour, that 
their primary digestion is not accomplished by bed time. Hence flatus and 
other symptoms of indigestion occur on lying down, and may prevent or dis- 
turb sleep, and the individual rises on the following morning with a pasty 
mouth and unrefreshed. To avoid these consequences, the supper should be 
taken at least two hours before going to bed, and should consist of such light 
nourishment as is easy of digestion, not too bulky, and not disposed to generate 
flatus. Those who use much exercise may take with advantage a little light 
meat, chicken, game, white fish, or lightly dressed eggs (with a small quantity 
of wine and water or sound beer if this do not disagree.) Those who require 
less sustaining food, as sedentary, plethoric, or inflammatory individuals, will 
find a more suitable supper in a light farinaceous pudding, bread and milk, or 
oatmeal porridge ; the last being especially useful in persons of costive habit. 
A few currants, raisins, or a little apple, with farinaceous puddings, counteract 
their constipating tendency. 

A habit of regularity in the hours of meals is of great importance in the 
preservation of health. The stomach acquires the habit of expecting and the 
power of digesting food at regular intervals, and various disturbances in its 



1 1 2 Principles and Practice of 

function and in the system result from irregularity. For this reason it is much 
better for those who cannot always dine early, to keep regularly to the late hour. 
The evil effects of long fasting are partly dependent on the infraction of this 
rule, but some result from inanition which has been noticed under the head of 
causes of disease. Few delicate persons can bear much exertion of body or 
mind before breakfast ; the practice of any early morning walk is only suited to 
the robust, who feed largely and late on the preceding day. When it is borne 
in mind that food is intended not only to supply the slower process of nutrition 
and reparation of the body, but also to afford materials for the immediate pro- 
tection of the blood against the chemical action of the oxygen absorbed in res- 
piration, and of the stomach against the chemical action of the gastric juice— 
the injurious tendency of long fasts will become apparent, and the more so in 
proportion as the small capacity of the digestive powers limits the quantity o* 
aliment taken at a time. 

OF CLOTHING. 

In a climate so variable as that of the United States, both nature and the tex- 
ture of the materials which compose our dress merit more particular considera- 
tion than in general is bestowed upon them. ■ Numerous diseases are to be as- 
cribed to the want of attention in accommodating our dress to the temperature 
of the climate, and to the various seasons and vicissitudes of the weather. It 
ought to be varied in point of thickness and warmth according to the sudden 
changes in the atmosphere, which occur at different seasons. It is, however, not 
intended to inculcate a scrupulous nicety in changing the dress with the daily 
fluctuations of the weather, but the general precept, not to dispense with the 
winter dress too early in the spring, nor retain that of the summer till the ap- 
proach of the boisterous season of autumn, should be most strictly regarded. 
Those who have a just conception of the baneful influence of intense cold, 
when applied to the skin, will duly appreciate the precaution above suggested. 
The Dutch are so sensible of the importance of guarding the body against 
cold, that they wear more than double the quantity of clothing that is customary 
in this country, and it is said that catarrh and consumptions are scarcely named 
in the catalogue of diseases among those people. 

The inhabitants of Canada are in the habit of wearing flannel next to their 
skins, and when exposed to the severity of the weather, they are wrapped in 
furs. Strangers who visit our country from abroad have frequently expressed 
their astonishment at our thin dress, so very ill adapted to withstand the inclem- 
ency of the weather in this cold and variable climate ; and they were at no loss 
to account for the colds, coughs, catarrhs, and consumptions so prevalent among 
our inhabitants. The mode of dress among our leaders in fashionable life, can- 
not but appear strikingly inadequate to the salutary purposes for which it is 
intended. 

It is not uncommon to see young gentlemen coming from a warm, close room, 
and exposing themselves to the severity of the cold, easterly winds, storms and 
night dews, with scarcely an additional garment. These votaries of courteous 
gallantry, it would seem are more solicitous to display a handsome form, than 
to adopt the means which Providence has put into their power for the preserva- 



American Medicine and Surgery. 113 

tion of life and health. Nor is the imprudent conduct among the other sex less 
reprehensible. In preparing for an evening visit, it is common for ladies to re- 
tire from a warm parlor to a cold dressing room, and, having changed a com- 
fortable, warm gown, for one of thin muslin with short sleeves, leaving the arms 
naked almost to the shoulders, and the neck and breast bare, or covered with 
thin lace, they walk through the streets with thin shoes, by which their feet are 
unavoidably wet and cold, and as the rules of politeness forbid their drying 
them in the presence of company, they sit a considerable time in a shivering 
condition. 

At length, tea being served and the fund of anecdote and conversation ex- 
hausted, they retire from a warm, crowded room, through the cold, damp- 
night-air, and soon go shivering to bed. Who will be surprised that the con- 
sequences of such imprudent exposure are catarrhal affection, affections of 
the chest and lungs, with cough and hoarseness, eventually terminating in fatal 
consumption ? 

Motives of delicacy as well as regard for health have beer: repeatedly urged 
in vain to enforce the necessity of relinquishing these destructive habits, the 
arguments of the moralist and of the physician having alike failed to convey 
conviction, hundreds who would now have shown forth among the loveliest of 
.the sex, have been dressed in shrouds, because in an evil hour they laid aside 
those parts of their apparel which health, as well as decency, forbade them to 
relinquish. In Scotland colds were extremely rare and consumption seldom 
met with, until the thick, warm, Scottish plaiding was relinquished for the thin 
English dress, when these disorders became extremely rife, and are now per- 
haps even mo're frequent than in any other part of the British Isles. The feet 
and chest are the two parts of the body which are more liable to receive the 
ill impressions of cold and communicate them to the 'rest, and these at least 
should be defended with the utmost care by covering them with flannel or 
fleecy hosiery. There is another custom introduced among young females 
which ought to be noticed here for the express purpose of bestowing on it the 
severest reprehension. It is that of wearing iron, or other hard substance, 
called corsets, against the breast-bone, with the view of improving their shape. 

Could they be made sensible of the folly and absolute danger of thus com- 
pressing the vital parts they would readily relinquish all claim to genteel ap- 
pearance, rather than incur the hazard which might attend the use of corsets 

From a just consideration of these circumstances, the question may readily 
be solved, why consumptions have so greatly increased among our young peo- 
ple of late years. 

The perfection of dress, considered merely as such, consists in its being ac- 
commodated to the form of the body without pressing or binding any part. 
Tight bandages about the neck are extremely detrimental. By impeding the 
circulation of the blood they often produce head-ache, vertigo and other more 
dangerous complaints, and when applied to the limbs they prove injurious by 
hurting their growth and occasioning lameness and many inconveniencies. 

The inquiry is often made, what is the covering most proper to be worn next 
to the skin? The advantages and disadvantages of a flannel shirt have re- 
8 



ii4 Principles and Practice of 

ceived such ample consideration of late years that little remains to be said on 
the subject, but to recommend the general employment of it as one of the 
most useful articles of wearing apparel. 

Experience has so fully evinced the utility of covering the skin with flannel 
that no person who has been habituated to its use in our damp and variable 
climate can be persuaded to dispense with it at any season of the year. 

It may not perhaps seem advisable to recommend the use of flannel shirts 
to infants and young, healthy persons, but to those who have passed the 
meridian of life, to persons of cold and phlegmatic habits, to such as are sub- 
ject to gout, rheumatism, colds and catarrhs, and, in short, to valetudinarians 
of every description, this article of dress sbould be considered as an indispensa- 
ble requisite. 

Linen shirts, when worn a few days, are net only liable to excite a sensation 
of coldness but to obstruct perspiration, which effect is produced in proportion 
to the thickness of the texture. Flannel, on account of the gentle friction 
which it occasions on the skin, produces a moderate warmth and promotes per- 
spiration, at the same time, on account of the porous nature of its substance, 
the matter which it absorbs from the skin is easily evaporated. 

By its gentle stimulus on the skin flannel has the beneficial effect of keeping 
the pores in a state the most favorable to a uniform perspiration, and when by 
brisk exercise the body is covered with the matter perspired, it passes off 
through the flannel into the a'r, and the skin remains dry and warm. But dur- 
ing a profuse perspiration in linen shirts the perspired matter, instead of being 
dispersed into the atmosphere, is retained by the linen, and not only clogs the 
pores but excites a very disagreeable sensation of chilliness, often followed by 
a violent cold, and sometimes even fatal effects. As flannel from its open tex- 
ture is not liable to retain the moisture discharged from the skin, people who 
wear it are far more secure from taking cold on going into the open air during 
profuse perspiration, than those who wear linen shirts. 

Prejudices have been excited against flannel by some people imagining that 
that it occasions weakness by too much increasing perspiration, but when it is 
considered that perspiration can seldom be immoderate as long as the skin re- 
mains dry, and that flannel tends to preserve it in this state, the objection will 
not appear to be founded in truth. 

It is granted that when flannel is first used it excites an unpleasant sensation' 
and the skin is apt to become red and inflamed, but this inconvenience is of 
short duration and will be deemed a trivial objection by those who know its 
many advantages. Instead of producing cutaneous eruptions, as some have 
asserted, a flannel shirt by preserving the pores open and increasing perspira- 
tion tends greatly to remove the cause of such affections. 

In short, there are no disadvantages attending the use of this valuable sub- 
stance, except the wearer neglects to change it sufficiently often to prevent its 
becoming disagreeable by being soiled and dirty. The practice of wearing 
flannel during the night is not only unnecessary but injurious. 

The object of using a flannel dress next the skin is to procure a uniformity 
•of temperature on the surface of the body, and thereby keep the highly impor- 



A merican Medicine and Surgery, 1 1 5 

tant but too much neglected function of the skin in an active and healthy con- 
dition. 

The body requires no extraordinary warmth during sleep, on the contrary 
there is at such times even a tendency to an increase of the natural warmth. 

A flannel dress worn next the skin throughout the night becomes so charged 
with perspiration that its power of conducting heat is thereby greatly increased 
and its preservative effects proportionately diminished. 

By substituting a coarse calico for a flarnel during the night, the body is kept 
in that temperature which fits it for encountering the vicissitudes of the follow- 
ing day, and the flannel, when resumed in the morning, will be in a state which 
contributes both to comfort and protection. 

The gratification derived from resuming a dry comfortable flannel in the 
morning, together with the sensible increase of its utility during the day, will 
be found to compensate amply for the slight unpleasantness attending the mo- 
mentary exposure to cold while exchanging it the preceding night. 

Such are the beneficial effects to be derived from the use of flannel, that it 
may be strongly recommended as a preservative of health, it is well suited to 
all seasons and may often render a cumbrous upper dress unnecessary. 

As a remedy in disease, a flannel shirt has been known to prove of great util- 
ity in gouty and particularly in rheumatic habits, and in obstinate coughs at- 
tended with symptoms of consumption. Upon the whole, this article of dress, 
considered both as a preservative and remedy of various diseases, merits a very 
general and extensive employment. In the late war those officers and soldiers 
who wore flannel waistcoats next to their skins not only escaped colds but 
dysenteries and other contagious disorders, while those who wore none were 
soon carried off by the diseases so commonly fatal in camps. 

Cotton is an intermediate substance between linnen and wool, although it in- 
creases warmth and perspiration, it is far from being conducive to the preserva- 
tion of health. A cotton shirt is very liable to imbibe and retain the matter of 
perspiration, and being accumulated in the form of a glutinous substance, 
obstructs the pores of the skin, and affords opportunity for the perspired hu- 
mors to be taken again into the blood to the great injury of health. 

Cotton stockings, for the same reason, are improper, and both linen and silk 
stockings have nothing but taste and fashion to recommend them. In fact, 
stockings made of wool, are greatly to be preferred to all others, on account of 
warmth and their quality of promoting a uniform perspiration. The old maxim of 
keeping the head cool and the feet warm, is not to be regarded in its strict, un- 
qualified sense. The covering for the head, like the other parts of the body 
should be accommodated to the state of the weather. There can, however, be 
no disadvantage in general in keeping it thinly and lightly covered, and, in many 
instances in young persons, the natural covering may of itself be sufficient pro- 
tection in moderate weather, and indeed those who accustom themselves to 
wear thick, warm caps in common, render their heads unnaturally sensible to 
all changes of the atmosphere. There are, nevertheless, certain persons who 
suffer inconvenience from the want of some moderately warm covering for the 
head, deafness, headache, and many other complaints are, on some occasions, 



1 i 6 Principles and Practice of 

to be attributed to this cause. The best general rule, therefore, is to avoid the 
two extremes of great heat, or improper exposure to cold, and when experience 
evinces the necessity of it, some proper covering, as a cap or wig, ought to be 
adopted. 

It is a point of great importance, during a hot season, to have the head prop- 
erly guarded against the intense vertical rays of the sun as inflammation of the 
brain, and even fatal consequences, have been known to ensue from an exposure to 
their influence, The common black hats, with very narrow brim, which are 
sanctioned by the present fashion, are evidently ill-calculated to shield the head 
from the solar rays. White, or light-colored hats, as they have greater power 
of reflecting the heat, ought in summer to be preferred to black, and the brims 
should be lined with green silk, and sufficiently wide to protect the eyes and 
face. The keeping the feet warm and dry, is to be considered of the greatest 
importance, since numerous diseases owe their origin to a want of care and 
attention in this respect. In consequence of cold and wet feet, the blood is ac- 
cumulated towards the head, a sensaticn of coldness over the whole body ensues, 
perspiration is obstructed, and not unfrequently a foundation is thus laid for in- 
curable disease. 

The feet, therefore, ought to be kept somewhat warmer than the rest of the 
body. Having said this much relative to the materials of our dress, it remains 
to be observed that the quantity must be determined by personal experience, as 
no general rule can be prescribed that will apply to every individual. It will, how- 
ever, be found a most salutary precaution on all occasions, so to increase or 
diminish the outer garments, that the body may, as nearly as possible, be pre- 
served in a natural and uniform temperature in all seasons of the year. 

It may be useful so make one remark here in behalf of those who labor under 
the infirmities of old age. Warm clothing, more especially warm bed clothes, 
are indispensably necessary to preserve or increase the natural heat of old peo- 
ple. 

OF AIR, OR ATMOSPHERE. 

Air is that invisible, transparent, compressible, and elastic fluid, which every- 
where surrounds our globe, and which generally receives the name of atmos- 
phere. It is the medium in which we breathe and without which we can- 
not exist. It is now very generally understood, that the atmospheric air, or that 
by which you are usually surrounded, is not a simple, but a compound body, con- 
sisting of at least four distinct substances, namely : oxygen, azote, carbonic acid 
and aqueous vapor. The two former substances, however, constitute almost the 
whole of the atmospheric air near the surface of the earth ; the other two are 
variable in their proportion, and exist only in minute quantities, which it is dif- 
ficult to appreciate. There are various methods known to chemists, by which 
these two airs may be separated from each other. Vital air or oxygen, which 
constitutes about one-fourth of the atmosphere, is necessary to respiration and 
combustion, and an animal immersed in it will live much longer than in the 
same quantity of common air. The remaining three-fourths, called azote or 
mephitic air. is totally incapable of supporting respiration or combustion for an 
instant. If a candle be included in a given quantity of atmospheric air, it will 



A mertcan Medicine and Surgery, 1 1 y 

burn only for a certain time and then be extinguished, as the oxygen is all ab- 
sorbed and the azote, which remains, is incapable of supporting flame. If an 
animal be immersed in a given quantity of common air it will live only a cer- 
tain time, at the end of which the air will be found diminished about one-fburth 
and the remainder will neither support flame or life. It appears that three 
parts of azote and one of oxygen, will form a compound similar to atmospheric 
air, and is that which is best suited to support the health of the body. Were 
the atmosphere to contain a much larger proportion of oxygen, by its powerful 
influence on the system inflammatory diseases would be induced, and the excit- 
ability be sooner exhausted. If, on the other hand, a much less proportion of 
oxygin should prevail in the atmosphere, there would be a deficiency of stimu- 
lus, and the excitability of our systems would morbidly accumulate, and diseas- 
es of debility would be the consequence. The oxygen which is received into the 
lungs of animals, is supposed to communicate the red color to their blood, and 
to impart heat and activity to the system. When animals die for want of vital 
air, their blood is always found black. 

There is a constant consumption of the oxygenous portion of atmospheric air 
by the burning of combustible bodies, by the fermentation and putrefaction of 
vegetable and animal substances, and by the calcination of metals. A greater 
or less proportion, therefore, of the noxious ingredient, azote, in our atmosphere, 
undoubtedly arises from the innumerable processes of combustion, putrefac- 
tion and respiration of men and animals, particularly in populous cities, the at- 
mosphere of which is almost constantly prejudicial to health. The atmospheric 
air is never absolutely pure and salubrious in any situation, but always mixed 
with heterogeneous particles, and the different states and changes produce very 
perceptible effects on the constitution. Warm air, if long continued, relaxes the 
solid parts of the body, quickens the circulation of the fluids, dissipates the 
watery part of the blood, renders the bile acrimonious and produces disorders 
in the bowels, and fevers of a malignant kind. 

A moist air is universally the most productive of diseases, but when heat and 
moisture are combined, it is of all conditions of the air the most destructive u 
the constitution, by impairing the elasticity of the solids, obstructing perspira- 
tion, and disposing to putrefactive diseases. A cold state of the air, if not ex- 
cessive and long continued, is favorable to bodily vigor, especially in those who 
are accustomed to take active exercise ; but extreme cold air, by constringing 
the solids and condensing the fluids diminishes perspiration, and often occasions 
rheumatism, catarrhs, and other affections of the lungs. The conjunction of 
dry and cool air is attended with salubrious effects, but a pure, dry air, mod- 
erately warm, is of all the most agreeable and salutary. 

All great and sudden changes from a warm to a cold air, and the reverse, 
produce in general a variety of complaints and frequently diseases of a fatal 
tendency. The surest mark of a salubrious and good air in any place is the 
longevity of the inhabitants. 

Winds, or currents of agitated air, likewise produce very sensible effects on 
the human constitution. A wind blowing steadily from the north purifies the 
atmosphere of noxious vapors, renders the air serene and dry, by which the 



1 1 8 Pri?iciples and Practice of 

system is invigorated and rendered active, though to persons of delicate habits 
it may prove severe and injurious. An easterly wind is cold without bracing' 
and in our climate is incomparably the worst of all others, uncomfortable, and 
the most prejudicial to health, especially on valetudinarians. To the asthmatic, 
and such as are disposed to intermitting fevers, it is particularly injurious. The 
coldness of our easterly winds in the spring is such as to occasion very uncom- 
fortable sensations in the generality of persons exposed to their influence. It 
has been remarked that the solvent power of an easterly wind upon the water 
is astonishingly great. After blowing over a large tract of the ocean, it con- 
tains much water, but is chemically combined with it, and consequently trans- 
parent ; it is also observed to take up more vapor from the ponds and meadows 
over which it passes than that which blows from any other quarter. The 
thermometer, of course, discovers the increase of cold consequent upon this 
evaporation. It has been observed that long continued easterly winds renders 
people who are naturally of a mild and placid temper irritable and morose, and 
that instances of suicide are most frequent in those countries and seasons where 
easterly winds are generally prevalent. The south wind is generally accompa- 
nied with a latent humidity which relaxes the body and disposes to affections 
of the head and breast. 

The atmospheric air, as already observed, is incessantly corrupted by the res- 
piration of men and animals, and by dissolution and putrefaction of innumera- 
ble substances. In populous cities the air is constantly contaminated with sul- 
phur, smoke and a variety of other exhalations of an adulterous tendency, and 
from which asthmatic and consumptive persons, and likewise those of weak 
nerves, experience the most prejudicial effects. 

It is therefore apparent that perso ns of this description ought, as much as 
possible, to avoid the corrupt air of large towns, or at least to change the air 
by frequently visiting other situations. In the open country there are few 
causes to contaminate the atmosphere, and the vegetable productions are con- 
tinually tending to render it more pure. The winds which agitate the atmo- 
sphere, and constantly occasion its change of place, waft the pure country air to 
the inhabitants of cities, and dissipate that from which the oxygen has been in 
a great measure extracted. 

Were it not for this wise provision of the Author of Nature, from the daily 
combustion of an immense quantity of fuel, the numerous substances constant- 
ly undergoing putrefaction, and the exhalations from a large number of people 
and animals, the air in populous cities and towns must soon become unfit for 
the purposes of life. 

The numerous chimney-fires in cities serve also an excellent purpose by rari- 
fying the atmosphere and thereby obviating the mischiefs which otherwise 
might ensue. 

The great importance of a pure air for the preservation of the lives of chil- 
dren is placed in the clearest light by the following instance : In the lying-in 
hospital at Dublin, two thousand nine-hundred and forty-four infants, out of 
seven thousand six hundred and fifty, died in the year 1872, within the first fort- 
night after their birth, which is nearly every third child. They almost all died 



A merican Medicine and Surgery. 119 

in convulsions ; many of them foamed at the mouth, their thumbs were 
drawn in the palms of their hands, their jaws were locked, the face was swollen 
and looked blue, as if they were choked. This last circumstance led the phy- 
sicians to conclude that the rooms in the hospital were too close, and hence, that 
the infants had not a sufficient quantity of good air to breathe ; they therefore 
set about ventilating them better, which was done very completely. The conse- 
quence is that " not one child dies now where three used to die." 

The air of any place where a numerous body of people are collected together 
especially if, to the breath of the crowd, there be added the vapors of a great 
number of candles or lamps, it is rendered extremely prejudicial, as it occasions 
great consumption of oxygen. The fact is well known, that when air has been 
long confined and stagnated in mines, wells and cellars, it becomes so extremely 
poisonous as to prove immediately fatal to those who imprudently attempt to 
enter such places. No person should descend into a well or cellar which has 
been long closed without first lowering down a lighted candle ; if it burn clear, 
there is no danger, but if it cease to burn we may be sure that no one can enter 
without the utmost danger of immediate suffocation. 

It sometimes happens also that when air is suffered to stagnate in hospitals, 
jails, ships, etc., it partakes of the same unwholesome and pernicious nature, 
and is a source of disease. It is obvious, therefore, that in all confined or 
crowded places, the correcting of vitiated air by means of cleanliness in every 
particular, no accumulation of filth about houses, clothes, or in the public 
streets, should, on any pretense, be suffered to continue, especially during the 
heat of summer. The pestilential effects which may be the consequence of a 
neglect of this salutary principle are almost inconceivable. The air is often 
rendered impure by hot fires or stoves in small rooms not sufficiently ventilated. 
This is peculiarly prejudicial to those who are subject to pulmonic complaints, 
and it ought to be cautiously guarded against. 

The warm rooms, which are usually an appendage to the luxury of the capi- 
tals, and thin clothing abroad, lay the foundation for many of those complaints 
which are the precursors of consumptions. It is thus that catarrh usually origi- 
nates in this country, and this always debilitates the lungs, and often terminates 
in consumption. 

It is a very injurious custom for several persons to sleep in a small apart- 
ment, and, if it be very close, and a fire be kept in it, the danger is increased ; 
and from this cause persons have been sometimes stifled in the night when 
asleep. It is deemed unsafe to leave the windows of a bed-room open at night 
during the summer months, as perspiration might be checked by the cool night 
air, while the pores are relaxed by the heat of the day and the warmth of the 
bed. 

The vapor of charcoal, when burnt in close apartments, produces the most 
dangerous effects. Our houses, which are made close and almost air-tight, 
should be ventilated daily by admitting a free circulation of air to pass through 
opposite windows ; and even our beds ought to be frequently exposed to the 
influence of the open air. Churches and other public buildings, if shut up for 
any length of time, and not properly ventilated by fires or open windows, and 



120 Principles and Practice of 

especially if not kept clean, are found to contain a damp, musty and contami- 
nated air, which proves extremely prejudicial to weak constitutions. 

Houses situated in low, marshy countries, or near lakes and ponds of stag- 
nant water, are constantly exposed to the influence of putrid vapors, which 
exhale from such noxious sources. To obviate this evil, fires should be made, 
during a sickly season, between the house and the place from which the putrid 
exhalations arise. But a very fertile and reprehensible source of poisonous 
vapors contaminating the air is that of church-yards situated in the middle of 
populous towns. The practice of depositing dead bodies in churches is still 
more liable to censure, as this forms a constant source of putrid vapors, how- 
ever imperceptible, which cannot fail to prove greatly destructive to health. 

Among the most powerful means furnished by nature of correcting air which 
has become unfit for respiration is the growth and vegetation of plants. The 
generality of plants possess the property of correcting the most corrupt air 
within a few hours when they are exposed to the light of the sun ; during the 
night, however, or in the shade, they destroy the purity of the air, which ren- 
ders it a dangerous practice to allow plants to vegetate in apartments occupied 
for sleeping, 

In order to a more correct understanding of the qualities and effects of air, it 
is necessary to advert to that property of living bodies which renders them sus- 
ceptible of external influence, generally termed excitability. 

" There are according to Dr. Garnett, three states in which living bodies exist : 
First. A state of accumulated excitability. Second. A state of exhausted 
excitability. Third. When the excitability is in such state as to produce the 
strongest and most healthy actions when acted upon by the external powers. 
These leading principles are of great importance, in many cases, towards ascer- 
taining more determinate rules of conduct relative to the prevention and cure 
of diseases." 

When the system is in such a state as to be very susceptible of the action of 
external powers, the excitability is said to be abundant or accumulated ; in a 
contrary state of the system, the excitability is said to be deficient or exhausted. 

When the action of the exciting powers ceases for some time, the excitability 
accumulates, or becomes more capable of receiving their action, and is more 
perfectly affected by them. This proposition may be exemplified by the effect 
of heat upon our bodies. If heat be for some time extracted, the excitability 
accumulates ; or, in other words, if the body be for some time exposed to cold, 
it is more liable to be affected by heat afterward applied. For instance, if one 
hand be put in cold water, and then both be put into water which is considera- 
bly warm, the hand which has been in cold water will feel much warmer than 
the other. If one hand be plunged into snow while the other is kept of the 
same heat as the body, and then both be held near the fire, the heat will affect 
the cold hand infinitely more than the warm one. In like manner, when the 
body has been exposed to excessive cold for some time, the excitability will be 
so greatly accumulated that if the heat of a fire be suddenly applied it will act 
with such violence as to occasion a high degree of inflammation, and even mor- 
tification may be the consequence. Hence chilblains, and other inflammatory 



American Medicine and Surgery. 121 

affections, are common with those whose hands and feet are exposed to violent 
cold, or wet with snow, and receive the heat of the fire without being first put 
into cold water or rubbed with snow. 

The great changes in the temperature which the air undergoes must have 
very considerable influence upon the constitution. In our climate the air varies 
from several degrees below the freezing point to more than ninety-five degrees 
of heat. We then experience the extremes of cold and heat by which our 
bodies are unavoidably relaxed and our constitutions exhausted. 

Heat possesses the property of stimulating and acting upon the excitability 
by which animal life is supported and continued, and without which we could 
not exist even for a few minutes. 

In a moderate temperature of air the stimulus of heat acts upon the excita- 
bttity without exhausting it to such a degree as to occasion disease. But when 
the degree of heat in the atmosphere is much increased and continues for a 
considerable time, an exhaustion of the excitability, and consequent relaxation 
and debility must be the result, as the common stimulant powers on which 
life depends cannot produce a sufficient effect upon the excitability to impart to 
the body that tone which is compatible with health. When, on the other hand, 
the stimulus of heat is much diminished, or when cold is applied to the body, 
the excitability must accumulate or become more susceptible of the action of 
external powers. It is not often, however, that ill consequences result from 
this condition of the system unless the exciting powers be improperly or too 
quickly applied, as we can bear a considerable diminution of heat with im- 
punity, and the action of cold, unless it be excessive, never produces any bad 
effects upon people in health. 

. It has been generally supposed that catarrh, or a cold, is contracted in conse- 
quence of exposure to cold air, but it is now ascertained that the immediate 
cause of that inflammatory affection of the mucous membrane of the nose, 
fauces and bronchise, which always attend catarrh, is not to be ascribed to ex- 
posure to cold air after being heated, but precisely the reverse of this takes 
place. It is not until we approach a heated atmosphere after coming from a 
cold one that we experience the symptoms of having taken cold. The cold air, 
drawn into the lungs by every breath, diminishes the heat of these parts, the 
excitability accumulates, and they become more liable to be affected by the suc- 
ceeding heat. While we continue in the cold air we are not sensible of any ill 
effects, but on coming into a warm room we soon experience the operation of 
those symptoms which evince our having taken cold, and the more we try to 
obviate these symptoms by the application of external heat, the more are they 
increased and aggravated. Such is the effect of violent action of heat on the 
accumulated excitability. 

"After cold," says a late eminent physician, " the sudden application of heat 
must produce the violent action which constitutes inflammation." The symp- 
toms are ascribed to the cold, and are the effects of an inflammation of the 
schneiderian membrane, which lines the nostrils, but it is the heat which is the 
immediate cause. We do not feel that we have taken cold till we are exposed 
to the action of heat, as when we come into a warm room, or in a warm bed, 



122 Principles and Practice of 

after exposure to a cold atmosphere ; and similar consequences are known to 
follow the application of heat to frozen limbs, viz., inflammation and mortifica- 
tion of the parts. The mistaken idea of " taking something warm to keep the 
cold out," occasions more colds, perhaps, than all the other exciting causes of 
the complaint united. 

It is a dangerous practice for persons when returning from an excessive cold 
atmosphere, to approach a fire without first waiting for the accumulated excita- 
bility to be gradually and moderately exhausted by the gentle action of heat, 
and to drink warm or strong liquors while the body is thus chilled with cold, is 
still more hazardous. When persons have their hands and feet exposed to in- 
tense cold by which the excitability of those parts is much accumulated, they 
will obtain the most effectual relief by putting them into cold water, or by rub- 
bing, them with snow until the morbid excitability be gradually exhausted. 

It is an erroneous idea, that people should cool themselves before going from 
a warm room into the open air; they should, on the contrary, accumulate a large 
portion of heat, and then secure their bodies by warm clothing and the use of 
active exercise, and, being thus prepared, they may pass through the most in- 
tense cold with perfect impunity. But after being exposed to cold air till the 
natural warmth begins to decline, they can never return into a warm room or 
near a fire without a risk of dangerous consequences. Let it, therefore, be con- 
stantly observed as a rule, that where the body or limbs are affected with in- 
tense cold, the only safe method is to produce the natural feeling and warmth 
by means of gradual heat. 

The fact seems to be fully established that, in proportion to the increased de- 
gree of the heat of the body is the safety with which cold may be applied, pro- 
vided it be applied freely and before the heat begins to decline. Of this we 
have a sufficient proof in the practice of the Russian inhabitants who first bathe 
in water heated to as high a degree as the body can bear, and immediately after 
roll themselves in snow, and this with perfect impunity. 

Few of the refinements of modern luxury and fashion are more prejudicial to 
health by rendering the body susceptible of cold than the living in small, close 
rooms, heated to excess by fires or stoves. 

Another practice, no less injurious, is to sleep in heated apartments upon 
soft beds, artificially warmed, and under a load of bed-clothes. 

It is far more salutary for the strong and healthy to go into a cold bed, re- 
garding it as a necessary rule, however, to acquire a moderate degree of warmth 
immediately previous to retiring to rest, for if we get into bed cold and chilly 
we shall remain so the greater part of the night. From the foregoing view ot 
the subject, it is obvious that nothing so much contributes to enervate the 
powers of the human frame as an excess of external heat, which debilitates by 
its perpetual stimulus, until the system becomes extremely sensible to the 
slightest variation of temperature of the air. It is of primary importance, 
therefore, that young persons be gradually habituated to bear the impressions 
of cold and induce that enviable state of hardiness that will enable them to 
brave with impunity the vicissitudes of the atmosphere of our ciimate. And in 
order to obviate the most frequent cause of catarrh, which is so prevalent among 



American Medicine and Surgery. 123 

us, we should accommodate our dress to the season and personal feeling, and 
when changes from cold to heat, or the contrary, are unavoidable, carefully 
guard against the transition being sudden and immediate. 

EXERCISE. 

The position is universally established, that exercise should be ranked as 
among the most powerful agents which we can employ for the preservation of 
life and health. The ancients, as well as the moderns, have attributed great 
utility in pursuing a proper course of exercise, and even considered it the sole 
instrument in the cure of some diseases, especially those of the glandular and 
nervous systems. 

Galen was a zealous advocate for the various kinds of exercise, as a curative 
remedy, and the great Sydenham was so exceedingly sanguine in his opinion of 
its salutary effects in the prevention and cure of numerous diseases, that he was 
led to give a latitude to it which can scarcely be admitted. Indeed, the benefi- 
cial effects to be derived from exercise, properly performed, in all chronic dis- 
eases, are almost inconceivable. It strengthens the solid parts, and promotes 
Ihe circulation of the fluids, beyond anything else within the compass of nature. 
It increases perspiration, and prevents many of those diseases which cannot be 
cured, and may remove others where medicine proves ineffectual. A common 
source of consumption in our females is want of exercise. There is no country 
in which the common habits of improved social life are adopted, in which this 
sex are less attentive to that most essential requisite for the preservation of 
health than in the United States. 

No exercise is equally salutary with that of walking. This gives action to 
the muscles of the limbs, where the circulation, from the distance of the ves- 
sels from the heart, is apt to be languid. It throws the blood forcibly forward 
towards the lungs, and thereby affords an opportunity for the mass to be ex- 
posed in larger quantities to the action of the air, by which alone it is rendered 
fit for circulation. This oxygenation of the blood by air endues it with the 
property by which it is enabled to excite its vessels into stronger action, and by 
that means to give strength and vigor to the whole system. Who does not no- 
tice that our sedentary females are put out of breath by the smallest degree of 
exertion, beyond what they have been accustomed to ? That the lungs have 
become so irritable for want of the stimulus which exercise exerts upon them, 
as to be thrown into a kind of convulsive cough from the most trifling acceler- 
ation of the blood in its passage through them. Whereas, in the females of 
our country towns, who have constantly habituated themselves to walking, 
riding and the greatest variety of domestic labors, may be noticed the large play 
of lungs in quick walking, a deep and full respiration, with all the attendant ad- 
vantages of a sufficient and complete oxygenation of the blood. Nor are these 
observations inapplicable to the other sex. 

There is not one man in a hundred who, from the nature of his occupation, is not 
obliged to do it, and not one in two hundred will do it from principle. The more 
active kinds of exercise — as running, leaping, riding, swimming, fencing, etc. — are 
the most suitable to youth and those of a middle age, and particularly to the corpu- 



124 Principles and Practice of 

lent. The passive kind— as riding in a carriage, sailing, swinging, etc. — are best 
adapted to infants, to the aged, and to the delicate and weak. Walking gives 
the most general action to the muscles of the body and limbs, but for the vale- 
tudinarians, and those who have weak bowels, or are consumptive, riding on 
horseback is preferable. It is almost incredible how much the constitution may 
be strengthened by this exercise, when continued for a considerable time, espe- 
cially when, on long journeys, a perpetual change of air and of scenes and ob- 
jects combine their advantages. Invalids who have recourse to this exercise 
should be accompanied by a cheerful companion, and they should not com- 
mence a journey for health until they have tried their strength in short rides, 
nor discontinue the exercise abrubtly, but gradually. 

They should divest the mind of all deep reflection, and gratify the sight with 
the prospect of the various objects which present themselves to view. The un- 
wholesome air of large towns, the damps of marshes, and the morning and 
evening dews, ought to be particularly avoided by invalids when traveling for 
health. It should be remarked that exercise immediately after eating is fre- 
quently productive of hurtful consequences, particularly in those of nervous 
and irritable constitutions, and fatiguing exercise should never be practiced till" 
the process of digestion is completed, which generally requires three or four 
hours after eating. 

The exercise of riding in a carriage is conducive to health, but the greater the 
motion allowed to the body of the carriage, the more beneficial will be its 
effects, provided too much fatigue be avoided. 

Dancing is a salutary exercise, especially in the winter, if not too violent or 
carried to excess ; but when performed in the warm atmosphere of a crowded 
assembly, and especially, if at the same time liquors of a heating nature be 
taken, or cooling drinks during a profuse perspiration, very serious conse" 
quences may be apprehended from such excesses. The laborious kinds of exer- 
cise attending agricultural employments, as hoeing, digging, raking, chopping, 
etc., have sometimes been found to produce advantageous effects. For chil- 
dren, skipping the rope is a salutary kind of exertion when not carried too far. 
Among the passive kinds of exercise, sailing is the most efficacious. The 
giddiness of the head, nausea and vomiting which is often experienced by 
those who are unaccustomed to the motion of a vessel, are productive of very 
salutary effects. Consumptive patients, if they have recourse to sailing at an 
early "stage, and also the nervous and hypochondriac, will often derive from this 
kind of exercise the most essential benefit. 

But to those who are subject to spitting blood, sailing is not to be recom- 
mended. Reading or speaking aloud is a salutary kind of exercise ; but to ex- 
ert the voice vehemently immediately after a meal is injurious both to the lungs 
and the organs of digestion. The action of singing shakes the lungs and the 
contents of the abdomen, which promotes in a remarkable degree, the circula- 
tion of the blood through those organs. But the reverse of this takes place with 
those who are much in the employment of wind-instruments, as they introduce 
a large quantity of air into the lungs, and keep that organ too long in a state of 
distention. Hence persons of weak lungs, who play much upon the flute or 



American Medicine and Surgery. 125 

or other wind instruments are frequently afflicted with spitting of blood, cough, 
shortness of breath, and pulmonary consumption. There is a species of exer- 
cise yet to be noticed as both gentle and useful, and in the power of every one- 
but which is too much neglected. I mean friction of the body by a flannel or 
coarse linen cloth. Friction is a kind of exercise that remarkably contributes to 
-the health of sedentary persons ; it excites and kindles the natural warmth, pro- 
motes perspiration, strengthens the fibres and tends to dissipate stagnant hu- 
mors. The operation is particularly beneficial to the nervous, debilitated and 
studious. 

The parts to be particularly subjected to this operation, are chiefly the ab- 
domen, spine, or back-bone, and the arms and legs. Even in a state of health' 
this kind of exercise will be found exceedingly useful, but in many chronic com- 
plaints it is an excellent remedy which cannot be to much recommended as a 
useful substitute for other exercise, which cannot be resorted to at all times. It 
should be performed every morning and evening, when the stomach and bowels 
are empty, and continued for twenty minutes at a time. In rubbing the abdo- 
men the operation ought to be performed in a circular direction, as being most 
favorable to the course of the intestines, and their natural action. It is proper 
here to remark that many ill-consequences may result from certain unnatural 
positions of the body, which sedentary artificers and others, are accustomed to 
practice. 

A bending posture of the body while sitting with the head inclined forwards, 
tends greatly to check the circulation of the fluids in the abdomen, and the head 
itself suffers by such inconvenient position. It is .likewise injurious to' the 
lungs, for when this organ is compressed, the air cannot have free access in al 
its parts so as to expand them properly ; the vital motions are thereby impeded 
and the health of course, must be greatly impaired. Those persons therefore, 
who spend much of their time in writing, should employ high tables or desks 
and raised seats, which will allow the body a more erect position. 

Artificers whose lower limbs are, constantly confined, as shoe-makers and 
tailors, ought to sit as erect as the nature of their employment will permit, and 
should change their position ,and make use of active exercise as frequently as 
possible. Although bodily exercise is an essential requisite for the preservation 
of health, this should not exceed the bounds of moderation, as too violent exer- 
cise, and a total want of it, are attended with equal disadvantages. 

MENTAL OCCUPATION. 

Under this head may be comprised a short notice of the mental influences 
which most conduce to the maintenance of health. As with the corporeal func- 
tions, so with the mind, a moderate and equabTe activity, with some variety of 
excitement and relaxation contributes to its well-being ; and inasmuch as the 
body is greatly under the influence of the mind, the health of both is, therefore, 
equally promoted. The kind -and amount of mental exercise must vary consid- 
erably, according to different circumstances of age, sex, temperament, capacity 
and habit of the subjects. 

The topic is far too wide to be comprehended in the very cursory glance 
which we can give to it, and it must suffice to notice some variations of mental 



126 Principles and Practice of 

discipline adapted to these different circumstances. In infancy the sentient and 
perceptive functions are active, the emotional feelings lively, whilst the higher 
moral and the intellectual faculties are very imperfect. Hence the sensitive ex- 
citability of this age, which becomes a frequent cause of disorder ; and to mod- 
erate this by various soothing expedients, as by gentle and lulling impressions 
on the senses, with timely resorts to varied amusing toys and other objects to 
divert attention and gently exercise the organs of sense and perception, is the 
chief aim at this early period. But as infancy passes into childhood, there is 
sufficient development of moral feeling and understanding to supply further 
means of control and direction, and although at this time it is equally necessary 
to avoid causes of fretfulness and passion, the principle of self-control and pa' 
tience may now be properly inculcated by moral and religious instruction, en- 
forced by a consistent example of kindness and justice in the conduct of those 
who manage the children. The mental as well as the bodily powers, at this 
early age, have no endurance, they are soon fatigued, and nothing can be more 
hurtful than to excite them too much, or too long, by games or scenes of 
amusement ; exhaustion, fretfulness and bodily suffering, are the common conse- 
quences of such excess and disease not unfrequently follows. A similar objec- 
tion may be urged against too early or too prolonged attempts to educate the 
mind ; such attempts anticipate the period at which the power of concentration, 
or sustained attention is acquired, which it can be safely only by time and prac- 
tice. Children precocious in intellect gain this power early, but this is a reason 
against its exercise, which would the more readily tend to strain the active facul- 
ties to a morbid degree. . 

As the mental capacity becomes enlarged by equal and judicious exercise in 
ripening youth, it is adapted to longer and severer tasks, and in addition to the 
advantages of thus improving the intellect by extended occupation at this age, 
the moral emotions and animal passions, which now acquire strength, are hereby 
moderated and kept in subjection. A leading rule to be observed in all attempts 
to develop and regulate the mind is, to exercise its powers as equally as possible ; 
the natural tendency is, that those powers which are constitutionally strongest 
should overrule and weaken others, and this applies to the impulses of moral 
feeling as much as to intellectual capacity. 

A main purpose of education is to prevent the inequalities by exercising the 
weaker powers, and judiciously restraining those which unduly predominate. 
Herein education includes not the mere communication of knowledge, but the 
discipline of the heart and mind, the subjugation of evil and useless inclinations 
and propensities, and the direction of the intention or activity of the intellect to 
objects that are profitable and improving. The influences by the aid of which 
this discipline may be exercised are manifold, and must, in some degree vary 
with the age and with the character of the individual. In childhood, respect and 
love towards parents or others exercising authority ; in youth, the same feelings 
confirmed and cultivated by the convictions of the understanding now giving 
increased spontaniety of thought to the individual ; and in all ages, the con- 
straining and elevating influence of religion in supplying the highest motives and 
rules for the conduct of thinking and responsible beings, these are the great 



American Medicine and Surgery. 127 

. 
leading instruments through which mental discipline is safely and effectively 

applied. 

But other and less dignified motives are often equally powerful, such as vanity 
pride, ambition, rivalry, and the like, and although they prove the failing of the 
human mind from a standard of perfection, and unless controlled may become 
exaggerated into vice, yet under restraint they may be usefully enlisted on the 
side of mental improvement. 

When youth ripens into adult age — although, technically speaking, education 
is complete — the discipline and culture of the mind (which are the objects of 
education) are still to be carried on with all the activity proportioned to the full 
development of the faculties and passions. 

This being the period at which the authority of parents or seniors is more or 
less relaxed, and the individual is of age to take full responsibility on himself, 
it is of the utmost consequence that his mature powers should be directed in a 
career which may promote his present and permanent welfare, and much, in re- 
gard to his future health, depends on the possessing such ascendancy of mind 
over body, of moral over animal feelings, as may secure the establishment of 
wholesome habits of wisdom and temperance. 

The subjugation of all gross appetites, the subordination of all turbulent or 
violent moral or mental emotions, the cultivation of the gentle and calming feel- 
ings fostered in domestic life or in refined social intercourse, and the regular but 
moderate application of the intellectual powers to some definite object or set of 
objects worthy of their pursuit, are items of mental discipline becoming the age 
of maturity, and, if steadily practiced, cannot fail to conduce not only to the 
health and endurance of both mind and body, but also to their lasting comfort 
and happiness. 

It is true that many difficulties beset the beginner in his endeavors to follow 
such rules ; many struggles against the inferior part of himself ; much exercise 
of patience and forbearance in regard to others ; a frequent practice of self- 
control in avoiding the temptations and excitement of intoxicating amusement, 
and a constant vigilance over the mind to restrain it equally from wandering 
into by-paths away from its proper road, and from lapsing into desultory ab- 
straction or indolence ; and these impeding forces within are often prompted or 
seconded by not less formidable obstacles without, thrown up by the multitudi- 
nous and ever-rising temptations and trials of life — never absent, but often pe- 
culiarly besetting its anxious and unsteady commencement. 

Need we say, then, that the efforts should be proportioned to the difficulties ? 
And with the full and rational exercise of human means, but with humble and 
faithful dependence on more than human guidance and strength, these efforts 
will never prove unsuccessful. 

But it is more especially our object to indicate the modes in which recipro- 
cally the mind and body may promote each other's health, and much may be 
summed up in the Platonic axiom that they should be well balanced in their ex- 
ercise and activity. The undue or too prolonged occupation of the mind with 
deep study or thought, abstracts the supply of blood and vital energies from 

e bodily functions; these suffer and fall into weakness and disorder, whilst 



128 Principles and Practice of 

the nervous system, the natural organ of the mind, is ultimately exhausted by 
the continued excitement, and refuses to perform one of its manifold functions ; 
hence stupor, paralysis, or organic weakness of some kind may ensue ; or others 
may retain a morbid erethism or irritation in the midst of general weakness ; 
and delirium, spectral illusions, sleeplessness, tremors, spasmodic or painful 
affections, may be the consequence. 

Mental idleness, on the other hand, not only weakens the intellect by disuse, 
but, by inducing habits of indolence and self-indulgence, pampers the body and 
perverts its proper functions, degrading them to approximation to brutal or even 
vegetable life. Moderate and well- timed exercise refreshes the mental powers, 
and, enabling them to apply with renewed vigor, increases their permanency 
and sphere of action. So, likewise, pleasing mental impressions, as from beau- 
tiful scenery, congenial associations and interesting pursuits, heighten the bene- 
fits of bodily exercise, and give all the faculties that renascent energy which is 
well expressed by the term recreation. A similar advantage accrues from vary- 
ing the kind of mental occupation ; thus music, drawing, amusing games and 
light reading are to many more effectual than absolute rest, in refreshing the 
mind after severe study or close application. 

In like manner intellectual tasks of different kinds may be profitably alter- 
nated with each other, as the several muscles of the body are more beneficially 
exercised in succession than all at once. 

Analogous rules may be applied to the moral emotions, so far as they can be 
placed under the direction of- the individual, and there is in most energetic minds 
somewhat of a natural or habitual succession of high and low spirits, of lights 
and shadows in the mental hemisphere, which, however trying and hazardous it 
may be in extremes, when occurring in moderation, gives a renewed vigor to 
thought which is wanting in minds of more perfect placidity. 

SLEEP. 

It would be quite superfluous to expatiate on the health-giving influence of a 
due amount of tranquil sleep. It is the chief means of recruiting the exhausted 
energies of the animal functions ; and some of the causes and consequences of 
its failures have been already noticed among the causes and elements of dis- 
ease. 

It appears to consist in a more or less complete suspension of the cerebral or 
sensorial functions, with an increase of the medullary and organic nervous in- 
fluence, and we have suggested that a modification in the distribution of the 
blood through the nervous centres may be instrumental in thus periodically re- 
ducing the activity of those parts which are not so essentially concerned in the 
maintenance of life. The sensorial functions are only impaired, not completely 
suspended, for a proof of their partial continuance during sleep is to be found' 
not only in dreaming, but also in the voluntary movements, often performed to 
remove uncomfortable sensations, and even in the act of awaking, when such 
sensations attain a certain degree of intensity. The approach of sleep is an- 
nounced by the feeling of drowsiness which consists of a dulness of sensation, 
perception and thought, and an indisposition to exertion. Gaping and yawn- 



American Medicine and Surgery. 129 

ing, although symptoms of supineness, result from efforts to resist it ; they seem 
to be movements designed to throw certain muscles, especially in the throat and 
neck, into a state of tension, during which the sensation of drowsiness is for the 
moment increased to a degree rather agreeable than otherwise, but followed by 
its diminution. It is very probable that these movements tend to re-excite the 
slackening cerebral circulation, by momentarily impeding it, and then allowing 
it to flow again with augmented force, a process like that of flushing. Sleep 
closes the relations of the senses to all moderate impressions of the external 
world and suspends almost all voluntary movements, among which are to be 
reckoned those supplementary to the process of respiration. 

The respiration is rendered, therefore, less frequent and more prolonged than 
when awake, and the pulse is also lowered. The circulation and changes of 
the blood being thus reduced during sleep, there is less power of maintaining 
animal heat, hence the chilliness of persons during and after sleep, and their 
susceptibility to cold, unless better protected than usual by clothing. 

Hence, too, the relaxation of the skin after slight febrile excitement, which, 
during sleep, yields to perspiration. 

The circumstances which promote sleep are chiefly those which impair the 
activity of the animal functions, and those which withdraw all causes of excite- 
ment to mind or body. 

A moderate degree of bodily and mental fatigue, the absence of all uneasy 
sensations, a comfortable posture, giving the most complete rest to the limbs 
and voluntary muscles'; a freedom from the feeling of either hunger, thirst, or 
repletion, cold or heat ; the periodic recurrence of a regular hour for repose, 
and the stillness and darkness of night, are favorable for the induction of sleep. 
In addition to these,' which act negatively by excluding excitement, there are 
others which are sometimes found to promote sleep by causing gentle and mo- 
notonous sensations or ideas, which have the effect of lulling into somnolence ; 
such, for example, as the various expedients for hushing infants to rest, by rock- 
ing, patting -the back, singing, etc.; and with adults, like soothing devices, some- 
times succeed, as by gentle friction, reading, prosy talking, and other dull im- 
pressions on the senses, which slightly tire without excitement. 

These probably operate by diverting the attention from other feelings, or 
noises, which, occurring occasionally, tend to disturb. 

The passes of mesmerism seem to act on the same principle. The expedient 
of counting or reciting one's self to sleep owes its efficacy (which is but small) 
to the abstraction of all attention to an uninteresting object. The influences 
which prevent or disturb sleep are for the most part the reverse of those last de- 
scribed. Any undue excitement or sensation of body or mind, whether of a 
painful or a pleasurable nature, strong, sudden or startling impresssions on the 
senses, uneasy postures, extreme fatigue or exhaustion, oppressed or imperfect 
breathing, palpitation of the heart, hunger, thirst, nausea, flatulence, and various 
other (often undefinable) sensations in the viscera, extremes of temperature, 
coldness of the extremities, irregularity in habits of getting rest, comprise the 
ordinary causes of sleeplessness. They operate either by directly exciting the 
sensorium to a degree inconsistent with the suspension of its functions, or by 
9 



130 Principles and Practice of 

so much reducing or disordering the power of the medulla, that it is incapable 
of sustaining the respiratory movements without the aid of voluntary effort. 
In the former case positive pain, uneasy sensation, or exciting trains of thought, 
are present. In the latter, there may be the desire to sleep, but no sooner does 
its commencement suspend the voluntary efforts by which the breathing is aided 
than this process becomes impeifect, and the person starts with a feeling of op- 
pression or impending suffocation, which his commencing dream impersonates 
into nightmare, or connects with the idea of being pursued by demons, falling 
down a precipice, or some such horrible catastrophe, which entirely precludes 
the reality of sleep. Such are the sleepless hallucinations of delirium tremens 
and similar disorders, in which continued excitement of the nervous system has 
exhausted the energy that is required in the medulla for the maintenance of 
respiration and muscular tone during sleep. 

The loss of rest is so seriously detrimental to health, that to prevent it by hy- 
gienic means is of great importance ; and, besides, avoiding as far as possible 
the several causes of wakefulness just specified, bad sleepers should take heed 
to attend the following directions for their regimen, rather than resort too hast- 
ily to hypnotic drugs, which although sometimes useful and necessary as temp- 
orary expedients, lose their effect by habitual use, and produce other evil con- 
sequences which render their continuance improper. 

Bad sleepers should make a regular practice of early rising. It may cost them 
some trial of strength at first, but if they would improve their sleep they must 
seek it at the natural time, and not late in the morning when the excitements of 
the day begin. 

Their hours of meals and exercise should also be early and most regular, both 
in order to promote that state of health most conducive to ease and freedom 
from suffering, and also to secure the accomplishment of the process of diges- 
tion and consequent excretion or eructation before night, which is the proper 
period for repose. Exercise should be used as freely in the open air as the 
strength will permit without causing lasting fatigue, and if the strength does not 
bear walking or riding, driving or sitting out in the open air several hours in the 
day is an efficient means of promoting sleep, by gradually and gently fatiguing 
the senses by the continued operation of light, air and sound, while the organic 
energies are refreshed and invigorated by their salutary influence, As the hour 
of retirement for rest approaches, every description of exciting agency should 
be avoided. 

The latest meal should be taken at least an hour before bedtime, and tea, 
coffee and all vegetable matters apt to generate gas, should be excluded from it. 
Weak persons, and others under the influence of fatigue, may often advanta- 
geously take a little wine or alcoholic mixture at this meal ; its operation, which 
counteracts the exhaustion and nervous excitement induced by weakness, being 
composing and hypnotic. All active exertion of body or mind should be care- 
fully avoided at this time. Subjects of conversation or reading should be com- 
monplace or tranquilizing, neither requiring much attention nor exciting to the 
feelings or imagination. The very preparation of undressing should be simpli- 
fied as much as possible, and all superfluous items or general washing, etc., 



American Medicine and Surgery. 131 

should be postponed until the following morning. Much might be said about 
the construction of the bed and its appendages, and the posture best suited for 
tranquil repose ; but this is not the place for such details, which may be com- 
prised in the general direction that all is to be made as comfortable as possible, 
without relaxing by excessive softness or abundance of covering. A soft upper 
mattress of hair, or wool and hair, is always preferable to a feather bed, not 
only in being less relaxing, but also in its giving a more elastic and even sup- 
port to the body and limbs, and prevent that sinking in of the body which 
fatigues a weak back by bending it. 

The posture most easy for the person is on the right side, which affords to the 
two weightier organs, the liver and heart, support which prevents them from 
pressing on the hollower viscera. 

A device which I have found to answer well in inducing sleep is founded on 
the attempt to imitate the mode of breathing of a person during sleep, by mak- 
ing the respirations, particularly the expirations, lower and more prolonged than 
usual, and giving to them somewhat of a sonorous character from the relaxed 
and, therefore, imperfectly open state of the glottis. 

This often excites a feeling of drowsiness, probably by gently retarding the 
return of blood from the brain, and this drowsiness may soon end in sleep, but 
it frequently happens with this, as with all other voluntary attempts to procure 
sleep, that the continuance of the effort breaks the spell by the awakening efforts 
of excited attention, and this objection especially applies to the first attempt to 
practice such invocations to Morpheus. The expedient recommended by Dr. 
Franklin to restore sleep that has been broken, by rising and shaking the. bed, 
with the view to change its air, is sometimes successful, particularly in hot 
weather. 

The amount of sleep most conducive to health varies considerably with age, 
sex, and constitutional and habitual peculiarities. Infants pass the greater part 
of the day as well as the night in sleep ; and children up to the age of six years 
generally require at least twelve hours of repose, besides an hour or more in the 
middle of the day. At about this age the sleep at noon may be discontinued, 
but the night can hardly be abridged with advantage until about the tenth year, 
and then only to a moderate extent until the period of puberty, after which it is 
generally proper gradually to reduce the period of rest to nine or ten hours, and 
no further diminution is expedient until the cessation of growth, when another 
hour or two may be taken from it. The average amount of daily sleep benefi- 
cial in adult and middle ages may be stated at eight hours. 

In more advanced life this extent of sleep is not less serviceable where it can 
be procured ; but at this period the capacity for sleep diminishes, and wakeful- 
ness or disturbed sleep is a common complaint of old age. Attention to the 
precautions before recommended will, however, often restore it, and even if 
they do not sleep, aged persons require an increased period of time in bed, for 
the sake of warmth and rest, which their reduced calorific and muscular powers 
render more necessary. 

Females stand in need of more sleep, commonly, than males, and during 
pregnancy and lactation additional rest is especially demanded, to assist the 



132 Principles and Practice of 

supplementary nutritive processes brought into operation in these conditions. 
In such cases, too, the loss of sleep is attended and followed by peculiarly in- 
jurious results, manifest especially in the nervous system, and general nutrition, 
in the form of mental derangement, impaired vision, deafness, paralysis, palpi- 
tation, convulsions, tremors, anorexia, wasting diarrhoea, etc. Under these cir- 
cumstances, a chief object of the treatment will be to procure sleep, and in ad- 
dition to regimenal means before suggested, nervous sedatives or hypnotics of 
the least depressing kind are required. Persons convalescent from acute dis- 
eases, or otherwise weakened and reduced, require and generally obtain more 
sleep than in ordinary health, and it is so efficient an influence in the pro-motion 
of recovery, that artificial means are sometimes properly used to procure it. 
So, likewise, those who use much active exertion need a longer period of repose 
than those who are sedentary ; and the same rule is applicable to persons whose 
intellectual powers are much strained, who should also use such exercise as may 
maintain the balance and promote the return of sleep. 

Salutary as is the operation of sleep in its due time and degree, it may prove 
injurious if indulged in to excess and at improper seasons. Too much sleep 
slackens the circulation, diminishes excretion and muscular nutrition, and causes 
general plethora or partial congestions, and in those disposed promotes the ac- 
cumulation of fat. By inactivity it weakens the muscular and sensorial powers, 
and gives an ascendancy to the medullary function. Hence a tendency to spas- 
modic and other nervous disorders of the system, which may further declare 
themselves in fits of hysteria or even epilepsy. In persons liable to this class 
of disorders, a judicious abridgement of sleep is often very beneficial ; and it is 
best effected by gradually establishing the habit of early rising. Undoubtedly 
the most fitting time for sleep is the night, and, although in these latitudes the 
nights are in summer too short and in the winter too long for the amount of 
needful repose, yet the more nearly this is assigned to the period when darkness 
and silence warn to rest, the better for the permanent comfort and well-being 
of the body. On the score of health, then, it is recommended that even adults 
should retire to rest, in summer especially, as many hours before midnight as 
can be spared after night closes, in order that they may be enabled to rise at or 
as soon after sunrise as they have had their proper complement of sleep. But, 
inasmuch as the usages of society and the business of life often make unavoid- 
able demands on the night hours of many persons, the compromise of retiring 
one hour before midnight should be enjoined for the sake of health, and accom- 
panied with an exhortation to early rising, enforced by a description of the re- 
freshing and invigorating influences of the morning air, with all the exhilarating 
concomitants of light and sound. 

EXCRETION. 

The absolute necessity of sufficiency in the processes of excretion for the 
maintenance of health, has been made apparent by the numerous instances 
cited in the preceding pages, in which their failure has led to the production of 
disease ; and although such instances commonly constitute such cases of dis- 
ease as require the application of medicinal means, yet the regularity and com- 



American Medicine and Surgery. 133 

pletion of the process of elimination may be so far promoted by common 
regimenal measures as to deserve a place among hygienic elements. Depend- 
ing, as excretion does, on the activity of the processes — of circulation, which 
regulates the supply of blood to the secretory organs ; of respiration, which 
improves the properties of that blood by renewing its chief chemical agent, 
and of assimilation, which adds to its materials ; of muscular contraction, which 
effects the expulsion of the excrementitious matter ; and of sensation, which 
takes cognizance of the need of its evacuation — it might be anticipated that 
the proper performance of this office (excretion) will much depend on the vig- 
orous condition of these several processes, which with it compose the sum of 
the general health. 

Hence many of the hygienic measures that have been recommended as con- 
tributing to sustain these several processes, are likewise efficient in promoting 
that of excretion. 

Thus a proper regulation of food, solid and liquid, and a regular use of exer- 
cise, are important means of favoring all the excretions ; and the functions of 
the skin and kidneys, and, in less degree, those of the liver and intestines also, 
are influenced by clothing, temperature, air and sleep. It will be sufficient to 
indicate a few of the more available means which are found useful in regulating 
the actions of the bowels, kidneys and skin in health. No circumstance tends 
more to promote the regular action of the intestines, than the punctual habit of 
daily devoting a fixed and sufficient time to their evacuation. Medical writers 
have long insisted on the importance of punctuality in attention to this office ; 
but they have not recognized the necessity of dedicating an amount of time 
sufficient for its proper completion, yet with persons of costive habit this is not 
of secondary consideration. In persons whose bowels act readily, an efficient 
peristaltic action forwards the feculent matter in consistence and quantity fitted 
for prompt and easy expulsion at the accustomed time,; but with those of tor- 
pid bowels (and they constitute a very numerous class, even among healthy 
persons), the excrement is more solid and the intestinal movement more tardy, 
and instead of being all in the rectum ready for delivery at the appointed hour, 
more or less of it may still be lagging behind in the sigmoid flexure or even 
above it, and cannot be discharged by a momentary effort. Nor will violent 
straining, (which is, moreover, injurious in other respects), properly aid in the 
process. 

Repeated gentle and sustained abdominal contractions, aided if necessary by 
kneading pressure, or friction downwards in the left iliac region, in the direc- 
tion of the sigmoid flexure, with some variation in the position of the trunk, are 
the safest and most efficient means of accomplishing this object; but they re- 
quire the sacrifice of a few minutes time, and if the end were not worth this 
sacrifice, I would not shock the delicacy of my readers by allusion to so disgust- 
ing a subject. 

These expedients are more easy and natural, and less injurious than the use 
of enemata, of which even the simplest kind, if employed habitually, injure the 
tone of the bowel, and impair its natural action. Other means may be men- 
tioned as serviceable in ordinary health to promote a regular and sufficient ac- 



134 Principles and Practice of 

tion of the bowels, such as the use of brown or rye bread, instead of white ; 
taking at night oat-meal porridge ; white mustard seed, stewed prunes, tama- 
rinds, baked apples, and the like, all of which act by adding either a mechanical 
or a chemical irritant to the feculant mass, and may prove objectionable by 
irritating too much and otherwise disordering the alimentary canal. 

The same objection applies to the addition of toasted bacon to breakfast, and 
that of a quantity of fruit to dinner. A more harmless, and sometimes more 
efficacious expedient, is that of drinking a large draught of cold spring water, 
at first rising, which is useful for other purposes likewise. 

"With some persons malt liquors promote the action of the bowels. A walk 
before breakfast for the more robust, or a walk or ride immediately after that meal 
for others, often contributes to the same end ; and in other instances such exer- 
tions as particularly bring into action the abdominal and other muscles of the 
trunk, such as digging, or other occupations in gardening, prove more effectual* 
Lastly, we must not omit to mention the habitual use of gentle aperient medi- 
cines, as the safest and most efficacious means of securing an adequate intesti- 
nal action in persons whose sedentary occupations or other circumstances abso- 
lutely prevent their adopting more strictly hygienic measures for the accom- 
plishment of the same purpose. Undoubtedly, it is preferable to avoid the con- 
stant use of medicine if dietic or regimenal management can be so conducted as 
to supersede it ; but much observation has convinced me that this cannot al- 
ways be effected, and then as a prophylactic or hygienic resource, a little daily 
pill is preferable to the practice of loading the stomach with indigestible matter 
with the object of stimulating the lower bowel. The excretion of urine is less 
generally an object of solicitude than that of alvine function ; yet it is remarka- 
ble how usually persons as they advance in years have their attention drawn to 
it, often from experiencing the discomforts of its irregularity or deficiency, and 
such irregularities are undoubtedly an important element in a vast proportion 
of disease, whether serious or trivial. It would occupy too much time to advert 
at length to disordered excretion of urine here ; in fact, the subject has been 
considered in almost every part of the present work ; and it must suffice to 
mention a few common hygienic influences by which the urinary excretion may be 
promoted or rendered more free. The abundance of urine, and therefore usu- 
ally its clearness and moderate specific gravity, will be generally proportioned 
to the amount of fluid ingesta ; but the increase is more sure when fluid, espe- 
cially water, pure, or with a very slight addition of vegetable or animal nutri- 
ment, is taken on an empty stomach. Thus, a large draught of spring water, 
drunk at first waking in the morning, or an hour before dinner, is almost surely 
followed by a free flow of clear urine. 

The result is promoted by such moderate exercise as excites the hearts' action 
without causing free perspiration. Some kinds of exercise peculiarly augment 
the secretion of the kidneys, especially those bringing the loins into action, as 
gardening, and trotting on horseback ; and these modes of exercise may there- 
fore be recommended to those whose secretion is defective, especially those lia- 
ble to lithuria ; for by increasing the watery constituent of the urine, there is 
less risk of any deposit taking place in the urinary apparatus. But similar 



American Medicine and Surgery. 135 

means, if regularly used, are useful also in gouty and rheumatic habits ; and 
they appear to establish an increased diminution of solid matter, as well as of 
water, by the kidneys ; and in this respect their operation differs from that of 
medicinal diuretics, which, unless very judiciously administered, excite for the 
time, und leave the secreting power exhausted afterwards. This is the chief 
objection also to certain diuretic beverages in common use, but as temporary 
expedients they are useful ; such as gin, Holland's, or whisky, diluted with water, 
spruce beer, imperial drink (water saturated with bi-tartrate of potass, sweet- 
ened and flavored), leek or onion-broth, barley water, linseed and tamarinds, 
Seltzer water, etc. Grapes, currants, and other ripe sub-acid fruits, also may be 
occasionally useful in the same way. 

The regular evacuation of the bladder, when distended to a certain degree, is 
prompted by the sensation excited, but in very various degrees in different indi- 
viduals ; some. either not feeling or resisting the want, and others yielding too 
frequently to its impulses. The latter extreme is too inconvenient, especially 
from its disturbing sleep at night ; but the habit of too long retaining the urine 
may prove pernicious in various ways, formerly specified, and should therefore 
be carefully avoided. In circumstances interfering with a proper observance of 
this caution, its urgency may be diminished by limiting the amount of liquors 
taken, and by promoting the cutaneous excretion by warm clothing and exter- 
nal warmth. 

The full purposes of the perspiratory secretion are not entirely known ; but 
its uses are recognized — in evacuating from the superficial vessels superfluous 
water, acid, and oily matter, under the distending or ex'citing influence of pro- 
longed heat or exertion, intending by its evaporation to cool the surface thus 
heated, and by its relaxing effect on the tissues to remove the irritation of dis- 
tention or obstruction ; and, by the same softening operation, to render the skin 
more pervious to the chemical action of the air on the blood, and to the vital 
influences reciprocated between the blood and the tissues. 

The excretion of the skin has been mentioned to be materially influenced by 
clothing, exercise, and temperature and air, and these are the chief means by 
which it is variously affected in healthy persons. 

Other hygienic measures for promoting the action of the skin are bathing, 
washing and friction. 

The chief operation of all these agents is on the skin, as an instrument of cir- 
culation and secretion, and in proportion as they are extensively applied they 
may exercise an influence on the whole system. 

Thus, warm bathing of the whole body, as it increases the amount and mo- 
tion of the blood in the cutaneous vessels, and the perspiration from them 
diminishes the supply to internal organs, and consequently the amount of their 
secretions. 

If continued long or repeated frequently, general weakness will result, the 
surface remaining in a relaxed state. The same objection does not apply to the 
occasional use of the warm bath, or the daily practice .of washing the whole 
surface with tepid sponging or shower bath, followed by friction, and these are 
highly salutary means of keeping the skin in a free and active condition well 



136 Principles and Practice of 

suited to persons of languid circulation. But in the majority of healthy sub- 
jects this object is better obtained by cold washing, and in the robust, even by 
cold bathing, in shower or plunge which indirectly excites the functions of the 
skin by constricting its vessels and thus throwing the blood on internal organs, 
and by impression on the incident nerves, causes the excitement of reaction, 
which soon restores the superficial circulation in redoubled force, with its con- 
comitant redness and glow. 

This reaction is much promoted by vigorous friction of the whole surface 
with coarse towels or horse-hair gloves, and this operates not only by stimulating 
the cutaneous vessels and glands, but also by the muscular exertion exciting the 
heart to stronger and more frequent contractions. For the same reason, other 
exercise, as in a brisk walk, is often useful. If after cold bathing the reaction is 
incomplete and the skin remains pallid, chilly and contracted, it may be in- 
ferred that the cold has been too long applied, and has permanently impaired 
the functions of the skin, and left the internal organs more or less contracted. 
Or if, after complete reaction, an unpleasant fatigue, languor, chilliness, head- 
ache, or other uncomfortable sensation remains, it is a proof that the cold and 
subsequent reaction have been too depressing or exhausting ; in either of these 
cases tepid bathing or washing is to be preferred. The vapor bath, with sham- 
pooing and various aromatic and stimulant applications, although a powerful 
remedial agent in cases of disease (especially chronic rheumatism and its con- 
sequence), is too exhausting to be recommended as a means of preserving 
health. 

A few general rules on the hygienics of sick persons will not inappropriately 
close this chapter. Patients laboring under acute disorders should be placed in 
large, dry and well ventilated apartments. The temperature of the room should 
be equable and moderate ; the amount of light must be regulated by the char- 
acter of the disease. When the air is contaminated by noxious exhalations, 
fumigations may be sometimes advantageously resorted to. If the room in 
which the patient is taken ill be small, badly ventilated or damp, he should be 
removed, if possible, into a larger one, free from these inconveniences, as the 
risks of moving, even in severe febrile affections, are less than is usually imag- 
ined. 

Great cleanliness should be strictly maintained, and for this purpose the linen 
should be frequently changed ; but not so as to fatigue the patient. It may be 
done even while the patient is sweating copiously and great comfort will result. 

To effect this warm clothes, passed underneath the shirt, should envelop suc- 
cessively the legs, thighs, abdomen, chest, and even the neck, so that the arms 
alone will be momentarily exposed to the air. Patients should never be permitted 
to sleep on feather-beds without an intervening mattress. It is often necessary 
to employ auxiliary means to receive the excretiops, impermeable cloths to protect 
the bed linen, and cushions to obviate the pressure on certain parts of the body. 

The position of the bed should vary according to the the nature of the dis- 
ease. The employment of suitable aliment and drinks in acute affections is of 
great importance, and adds materially to the comfort of the patient. There are 



American Medicine and Surgery. 137 

two extremes to be equally avoided — nourishing patients too much and not 
nourishing them enough. 

Hippocrates thought it safer to err on the side of the excess, than for patients 
to observe total abstinence. In acute febrile affections you should observe a 
just medium. Prohibit all kinds of solid aliment, but permit the use of fluids 
slightly nutritious, such as farinaceous articles, light broths of veal and chicken, 
the juicy fruits, etc., when the febrile movement is not too high. In the low 
forms of fever, when the strength has to be supported, it is indispensable to 
nourish the patient, and severe adynamic symptoms may often be prevented by 
timely nourishment. 

The injudicious use of food has the power, it has been remarked by a cele- 
brated authority, of nourishing the disease and not the patient. It is of im- 
mense importance in all acute disorders that the excretions of the patient 
should be immediately removed. Perspiration chills the body ; the urine and 
fecal matter already compromised, are disposed to speedy decomposition, and 
impart noxious qualities to the air. When involuntarily excreted, their contact 
with the body is positively injurious, by provoking eruptions, excretions and 
even sloughing. 

In acute diseases, repose and quiet are indispensable. Sydenham thought 
that fever patients should be made to rise every day, and that doing so obviated 
the tendency to delirium. There is no doubt but that patients should be daily 
placed in an arm-chair, or on a bed, according to their strength, in order to al- 
low their own bed to be made ; if this cannot be done, they can be removed to 
another portion of their bed, whilst the necessary change is made. When a 
patient is too feeble to change his position in bed, it should be done for him fre- 
quently, it adds materially to his comfort, prevents the formation of sloughs and 
obviates the tendency to pulmonary congestion, so frequent in protracted fevers- 
Sleep is generally a favorable symptom in acute diseases. Every thing which 
by acting on the senses, or the moral of the patient will prevent it, should be 
obviated. From the same motives sleep should not be broken to administer 
medicines, without the necessity is urgent. Sleep may sometimes be induced in 
convalescence, by causing the patient to rise and re-adjusting his bed. Gentle 
friction with the fingers on some part of the body disposes to somnolency. The 
sensations, the emotions and intellectual faculties all demand, in a special man- 
ner, the attention of the physician. 

The removal of all moral or mental circumstances, which either have pro- 
duced or keep up the morbid condition, is important. Conversation should be 
banished from the sick chamber ; when low it is annoying ; when loud, fatiguing 
and exciting. The influence of the passions of the mind is so great that noth- 
ing should be neglected to give them a favorable turn. To this end the physi- 
cian should obtain and deserve the confidence of the patient, (careful and great 
interest will frequently accomplish this,) and he should be careful that nothing 
in his speech should betray anxiety or uneasiness. Patients generally receive 
with satisfaction assurances of the successful termination of their complaint 
from their physician. 

The fear of death adds materially to the danger in a majority of instances, and 



138 Principles and Practice of 

" the physician" says Chomel, " who allows his patient to suspect the danger of 
his position, diminishes the prospects of his recovery." Sir H. Halford, in some 
judicious remarks on the duty of a physician, in withholding from, or commu- 
nicating to, a patient the probable issue of a disease displaying mortal symptoms, 
says, " that the first duty of a physician is to protract the life of a patient by all 
practical means." The probability of a fatal issue, therefore, should be commu- 
nicated to the friends, and, except under very peculiar circumstances, never to 
the patient. 

In chronic diseases hygienics are of immense utility. Change of habitation 
and climate, voyages by land and sea, a sojourn at some fashionable watering 
place, etc., often succeed in restoring health when all other remedies fail. 



American Medicine and Surgery. 130 



PRACTICE OF MEDICINE. 



CLASSIFICATION OF DISEASES. 



Diseases have been classified by writers according to their fancy or conveni- 
ence. First classified by Celsus, who associated those bearing to each other a 
general resemblance. The second classification was Coelus Aurelianus who di- 
vided them into acute and chronic. The third classification was founded on the 
locality, beginning with the head and proceeding to the chest, etc. A fourth, 
adopted by Boerhaave, was founded on the supposed causes of disease. I shall 
not notice all the plans of nosologists who have contended for special arrange- 
ments, but like those who have gone before, shall adopt the classification best 
suited to my purpose, which will be, 

1st. Fevers and inflammation. 

2d. Diseases of the sensitive system, brain, spinal marrow, nerves, and organs 
of sense. 

3d. The Circulatory system of heart and blood vessels. 

4th. The Alimentary — of stomach and bowels. 

5th. The Respiratory, Pulmonary organs and their immediate extension. 

6th. The Secretory — of the glandular apparatus. 

7th. The Absorbent, Lacteals and Lymphatics. 

8th. Perspiratory, external covering of the body. 

9th. The Muscular — of the muscles and their appendages. 

10th. The Osseous — of the bones and their connections. 

nth. Generative and Urinary — of the organs subservient to these processes in 
both sexes. 

We would, however, prefer the classification of disease according to tissues 
involved, but as several tissues are often involved in the same affection, this is 
impracticable. We, shall as far as possible, adhere to the classification given 
above and while not claiming perfection in our arrangement, we believe it is the 
one most convenient to students and practitioners. 

FEVER 

There is no one derangement of the human system that has given rise to more 
discussion and theorizing than fever. It has been a matter of speculation among 
medical writers as far back as we can trace medical literature, and doubtless 
puzzled the brain of man since the first appearance of disease in the human 
race. We may agree on other diseases or derangements as to cause, e ff ect, etc. 
but each system has a peculiar doctrine as to fever. 



140 Principles and Practice of 

No derangement is so common as fever, none in which the non-professional 
are so little likely to be mistaken, and yet how difficult to define ! In fact no 
writer of the schools seems to have been satisfied with his own definition. The 
first theory of fever was that of the Greek school, promulgated by Hippocrates 
and supported by Galen. This theory we hold as correct, or rather as the 
foundation of a correct definition of fever. It was in substance that fever is an 
effort of nature to expel something hurtful from the body either ingenerated or 
introduced from without. 

Hippocrates expressed it as a violent commotion in the system followed by an 
evacuation from the skin and kidneys with which the paroxysms terminated. He 
goes further, and ascribes the commotion to a fermentation, concoction or eb- 
ullition by which the noxious matter was separated from the sound humors, and 
the evacuation to a deposition or scum which such separation produces, or rath- 
er to the discharge of this morbid scum from the emunctories that open exter- 
nally. This was the only theory taught or definition given of fever for a period 
of over three thousand years. 

Paracelsus and Van Helmont, showing the same narrow-minded bigotry that 
characterizes their followers of to-day, attempted to obliterate the whole system 
of Hippocrates and Galen, and with solemn pomp condemned and burned the 
entire works of these old reformers. This doctrine of fever, however, blen- 
ded itself with the dialect of the chemists, and though crushed to earth still 
lived, as great truths always will. 

This theory of fever was maintained until its opponents claiming that agents 
given to increase the heat or assist nature, produced dangerous and fatal re- 
sults, and to this hue and cry, no doubt holding up all the fatal cases that could 
be found thus treated, the world is indebted for the partial suppression of the 
practice founded upon this theory. The second theory of, or definition of, fever, 
was promulgated by Boerhaave, and which owing to the unfair rfteans just men- 
tioned, became so popular as to triumph over the Greek theory. His theory 
was that the blood was chemically changed ; that we had a crusty or sizey con- 
dition of the blood which, from its action upon the larger vessels, etc., produced 
fever, and his treatment was to introduce agents into the system to dissolve or 
neutralize this principle and thus cure fever. 

We pass now to the third theory of fever, which was promulgated by Cullen. 
based upon the theory of Stahl and Hoffman. 

Cullens' doctrine is that, " The remote causes are certain sedative powers 
applied to the nervous system, which diminishing the energy of the brain, there- 
by produce a debility in the whole of the functions, and particularly in the ac- 
tion of the extreme vessels. Such, however, is at the same time the nature of 
the animal economy, that this debility proves an indirect stimulus to the san- 
guinerous system ; hence, by the intervention of the cold stage, and spasm con- 
nected with it, the action of the heart and larger arteries is increased, and con- 
tinues so, till it has the effect of restoring the energy of the brain, of extending 
this energy to the extreme vessels, of restoring therefore their action, and there- 
by especially overcoming the spasm affecting them, upon the removing of which 
the excretion of sweat, and other marks of the relaxation of excretories, take 



American Medicine and Surgery. 141 

place." And this is the accepted definition of fever among the regular practi- 
titioners of to-day. 

This definition of Cullen's did not prove satisfactory to all in his school even, 
and, as a result, Dr. Brown's theory was promulgated, which is : " Man is an 
organized machine, endowed with a principle of excitability, or predisposition 
to excitement, by means of a great variety of stimuli, both external and inter- 
nal, some of which are perpetually acting upon the machine ; and hence the 
excitement which constitutes the life of the machine is maintained." 

Excitability, therefore, is the nervous energy of Dr. Cullen, and like that is 
constantly varying in its accumulation and exhaustion ; yet not like the nervous 
energy of Dr. Cullen, under the direction and guidance of a vis conservatrix et 
medicatrix natures, distinct from the matter of the organization itself, but pas- 
sively exposed to the effect of such stimuli as it may chance to meet with, and 
necessarily yielding to their influence. 

Upon this hypothesis, excitement is the vital flame, excitability the portion of 
fuel allotted to every man at his birth, and which, varying in every individual, 
is to serve him without any addition for the whole of his existence ; while the 
stimuli, by which we are surrounded, are the different kinds of blasts by which 
the flame is kept up. If the fuel, or excitability, be made the most of, by a due 
temperature or mean rate of blasts or stimuli, the flame or excitement may be 
maintained for sixty or seventy years. 

But its power of supporting a protracted flame may be weakened by having 
the blast either too high or too low. If too high, the fuel or excitability will, 
from the violence of the flame, be destroyed rapidly, and its power of prolong- 
ing the flame, be weakened directly, and to this state of the machine, Dr. Brown 
gave the name of indirect debility, or exhausted excitability. If the blasts, or 
stimuli, be below the mean rate, the fuel indeed will be but little expended, but 
it will become drier and more inflammable, and its power of prolonging the 
flame will be still more curtailed than in the former case ; for half the blast that 
would be required to excite rapid destruction antecedently will be sufficient to 
excite the same effect now. 

This state of the machine, therefore, the author of the hypothesis contra- 
distinguished by the name of direct debility, or accumulated excitability. Upon 
these principles he founded the character and mode of treatment of all dis- 
eases. They consist of but two families, to which he gave the name of sthenic 
and asthenic ; the former produced by accumulated excitability and marked by 
direct debility; the latter occasioned by exhausted excitability, and marked by 
indirect debility. The remedial plan is as simple as the arrangement. Bleed- 
ing, low diet, and purging, cure the sthenic diseases, and stimulants of various 
kinds and degrees, the asthenic. Fevers, like other diseases, are either sthenic 
or asthenic ; they result from accumulated or exhausted excitability. Synocha, 
or inflammatory fever, belongs to the first division, and typhus to the second." 

Other pathologists have advanced special doctrines, or definitions of fever, 
some claiming that inflammation and fever are identical, but all these may be 
met with the general answer that, though fever is commonly a symptom or 
sequel of inflammation, inflammation is not uncommonly a symptom or sequel 



142 Principles and Practice of 

of fever. The fact that post mortem has shown inflammation of the brain, 
stomach, etc., in those who have died of disease in which fever is an attendant, 
does not prove that the fever originated in the inflamed organ. The same ap- 
pearance may take place equally as an effect and as a cause. As it still re- 
mains a matter of doubt with the systematic writers* what part of the human 
system, or particular vessel, is first impressed by the morbific agent, I shall en- 
deavor to show that the first impression is made upon the capillary vessels and 
nerves, in their terminating extremities, on the two tegumentary surfaces and 
organs, at thc'r connection with the secerning arteries and secretory vessels. 

And when reference is made to the capillary vessels and nerves, I wish it un- 
derstood that the connections are included. But as there has been, and still 
exists, a diversity of opinion in relation to the first local impression made upon 
the system, it will be necessary, in establishing my position, to examine the nat- 
ural emunctories that have been wisely established as outlets to guard and pro- 
tect the system against the retention of effete matter in the circulating fluids. 

By these outlets we find nature, under the influence of an inherent power, 
When the system is in the full enjoyment of health, throwing off everything that 
is foreign to the laws of life, while in fever those excretory outlets are arrested 
or perverted in their functions, and as the first impression made upon the sys- 
tem by any morbid agent is discoverable through the secretory and excretory 
organs, a cursory view of their offices, and the two systems that are liable to de* 
rangement, will be necessary for a clear understanding of the subject. 

The body being covered with a tegumentary substance called ths skin, through 
the pores of which the sensible and insensible transpiration pass, it will be seen 
that in a majority of attacks the functions of those emunctories are, to a greater 
or less extent, suspended or morbidly exalted. This fact, if there were no other, 
affords at least presumptive evidence that the first seat of this disease will be 
found upon their extremities. But the anatomy of the tegumentary system de- 
monstrates the final termination of the nerves and capillary vessels, with the 
branches of the arteries, which exhibit the connection of the secretory follicles, 
that separate from the fluids the sensible or insensible exhalations. 

When examined by a microscope, it appears as though these emunctories are 
composed of the extremes of the nervous and circulating systems, and that in 
their ramifications their functions are dependent upon their healthy condition. 

The internal tegumentary system is the mucous membrane, lining the internal 
organs, and on their surface we find the same arrangement of the two systems 
in their terminations, and, in a majority of case, Li the initial stages of fever the 
functions are alike deranged. 

The lungs, having similar offices and endowments, are observed to suffer in 
like manner ; and, indeed, when we confine ourselves to close observation, the 
same may be said of the functions of the liver, the kidneys, and of all the secre- 
tory organs. 

From their arrangement, and from what we observe in health and in disease, 
it is a fair inference that the changes produced by morbific agents are first upon 
these two systems. From some causes, the internal nerves and capillaries receive 



American Medicine and Siirgery. 143 

the shock, and from others the external extremes become the subjects of the im- 
pression. Consequently it is evident that the two systems are the first deranged. 

This being uniformly the case, it is of but little importance in the cure whether 
the morbific agent be heat, cold, or marsh malaria* But to say that the nervous 
system is the first in fault, in all the forms of fever, would be absurd, and the 
same remark may be applied to the charges against the circulating system. 

The mistaken notions of the humoralists, and their antagonists, in my opin- 
ion, derive their origin from a misapprehension of the dependencies of the nerv- 
ous system and the vital circulating fluid in their intimate connections. 

The brain, with all the other parts of the system, is formed and sustained 
from this vital fluid, which is declared to be the " life of the animal creation;" 
and from the facts observed in the organization of man, it is already manifest, 
from the different degrees of sensibility and irritability in the tissues. It is true 
the nervous system possesses a greater degree of sensibility, but it must not be 
inferred that the balance of the subordinate systems is wholly dependent upon 
the nerves for their sensibility or susceptibility. Such an inference would leave 
these systems without the capacity to act or be acted upon, and would assuredly 
destroy the principles of life contained in the constituent elements of the blood, 
which constituent elements give to each tissue or organ the peculiar property 
for the purpose of endowing the parts with the energy requisite to the perform- 
ance of their functions. For the purpose, therefore, of contrasting the acknowl- 
edged causes and effects, we will examine some of the more prominent, that act 
deleteriously upon the human system. The first are recrementitious substances 
retained in the circulating fluids — such as checked perspiration, bile and uric 
acid. These recrementitious fluids, when retained in the circulation, frequently 
give rise to disease, by establishing irritation. Checked perspiration is also 
most frequently acknowledged to be a secondary consequence ; so, also, is bile 
and uric acid. 

But the influence of such causes is calculated to establish irritation and vascu- - 
lar action ; and checked perspiration not unfrequently deranges the functions of 
the kidneys by the vicarious action induced by these organs which produces ex- 
haustion. 

The second cause to which the writers refer is irritation produced by indiges- 
tible substances, or by worms, etc., generated within the body. The third cause 
is attributed to deleterious substances floating in the air, or the variable condi- 
tion of the atmosphere, such as miasmata, noxious gases, heat, cold, electricity, 
humidity and contagious or mechanical causes. 

That the above causes are calculated to produce disease, no one doubts, but 
are there not many reasons for believing that an excess of these causes is harm- 
less, unless too long continued in action, or when the system has been previously 
weakened by antecedent causes. In health we find the human system is capa- 
ble of resisting heat and cold, in a wonderful degree. The fire-king at a tem- 
perature sufficient to roast a beef-steak, is enabled to withstand the heat with- 
out apparent injury, and mankind are enabled to approach the other extreme, and 
brave the cold of the frigid zone, where mercury is frozen, without injurious 



144 Principles and Practice of 

consequences. But if the system had been previously debilitated, either of the 
above causes would have established morbid action. 

The effect of cold or heat too long continued, is well understood by the pro- 
fession, and in their extremes or sudden vicissitudes, is admitted as a fruitful 
predisposing cause of fever in some, and in others, an exciting one. In many 
of the other admitted causes, the constituents are not understood, nor is the 
channel known by which they enter, although it is supposed that it is by inhala- 
tion of animalculi or by being incorporated with the saliva, and taken into the 
stomach. Either of which must make a direct impression, to establish morbid 
action. If this be the case, is it not probable that many of these agents are 
condensed upon the cutaneous surface, and make a direct impression upon the 
nerves and capillary vessels through the external absorbents. From what I 
have observed in marshy districts, I believe those agents gain admittance 
through inhalation as well as by absorption, both externally and internally ; 
namely, through the salivary glands, and if not thrown off enters the circula- 
tion by absorption, but I do not believe it is necessary for the morbific agent to 
become incorporated in the circulating fluids, and thereby change the constitu- 
ents of the blood before the poison is capable of establishing morbid action. 
Nor is it consistent with the physiological laws observable in the movements of 
the economy ; for on being impressed with a medicinal agent, we find the vital 
action making an effort to expel the offending cause by the outlets provided for 
that purpose ; and through these natural outlets deleterious agents are elim- 
inated and thrown off from the system in such a hurried manner that it is im- 
possible that they should have been conveyed into the circulating mass, and 
passed through the heart before morbid vascular action was established. To 
admit in all instances the incorporation of such materials with the blood, would 
be presuming that nature had not been provided for in the way of protection 
and defense. 

That many articles are absorbed, and conveyed into the fluids cannot be 
doubted ; but is it not reasonable to suppose that the various deleterious agents 
inhaled and absorbed are only permitted to enter that part of the circulating 
system which conveys the limpid or white fluid ? as those capillary vessels ap- 
pear to be possessed of an inherent power to resist the entrance of any material 
that is incompatible with the well bejng of the economy, until the vital forces 
are enfeebled or overcome by the long continued application of morbific agents, 
or some violent cause. After which the entire circulating fluid becomes con- 
taminated by the virus which has entered the system. Hence morbid vascular 
action is frequently established giving - rise to fever, without the entrance of the 
morbific agent into the red part of the circulating fluid as we see that the force 
of some of the noxious gases and poisons is sufficient to destroy life, when 
brought into contact with the respiratory mucous membrane, or any part of the 
vascular system. In many cases the effect is too sudden to admit of the belief 
of its absorption. Yet many of these deleterious agents when absorbed in a 
diluted form, are completely under the control of the vital forces of the system. 
In some marshy districts the miasm is so abundant as to derange the capillary 
vessels and nerves, and in some constitutions, to establish fever of an intermit- 



American Medicine and Surgery. 145 

tent or remittent type in a few days ; whilst in others, the effect of the malaria 
is successfu'ly resisted and thrown off by the vital action of the system, not- 
withstanding the constitution is enfeebled by the continued application of the 
miasmata. 

In such cases, notwithstanding the efforts of the vital power of the system, 
the aspect of the countenance gradually assumes a sallow hue, until in some the 
capillary vessels and nerves are so far overcome, that dropsy is the result; 
whilst in others in a more southern latitude, by the increase of malaria and the 
changes in temperature, we have those violent attacks of yellow and congestive 
fevers. As it has been shown that the capillary vessels and nervous termina- 
tions are so intimately connected, it will be seen that whatever deranges the one, 
will simultaneously derange the other. This fact is abundantly exemplified in 
cases of fright, or cold water suddenly douched upon the lower extremities, each 
acting upon the bowels through contiguous sympathies, and also in abrasions of 
the surface produced by the explosion of steam, from the shock of which we 
find symptoms of compression of the brain. Hence, I infer, that in proportion 
as the qualities of the poison are obnoxious to those sentinels of life posted ex- 
ternally and internally, so is the shock to the system, inducing the overthrow of 
the functions of the entire economy. 

These terminating extremes of the nerves and capillaries of the circulating 
systems may be properly denominated sentinels, to warn us of the gathering 
clouds of disease, which are first manifested in the change produced upon them 
and from their angry appearance, we are induced to furl our sails and prepare 
for the tempest that is fast approaching. But these are not the only important 
services of these little sentinels.. The evidence of returning health, the effect of 
the remedial agents, their assistance in ejecting from the system the offending 
cause, are among the objects that render them worthy the closest attention of 
the profession. 

If we examine the action of the economy under the influence of lobelia, we 
find that as soon as the agent is brought in contact with these guardian vessels,, 
the physiological laws of the parts are increased by the stimulant applied to 
the vessels and nerves, which enables nature to free herself either by ejecting 
from the stomach, or hurrying through the alimentary canal, the cause of the 
difficulty. 

This speedy response of nature will rrot admit of the belief in the absorption 
of the lobelia into the general circulation before its effect is produced, but by 
the impression it makes upon those vessels establishes exalted action, and 
thereby Irees the system from the offending cause, so it may safely be inferred 
some morbific agents are too powerful in their action to admit of absorption 
but perhaps if diluted, or of a less offensive quality, they may be absorbed to 
the extent as before stated, and when thus far taken into the circulation, may 
establish fever from irritation or congestion. 

"Any cause," says Prof. Wood, " capable of inducing irritation in any con- 
siderable number of the organs, or over any considerable portion of the body, 
either by direct impression, or by the reaction which follows depression, or by 
10 



146 Principles and Practice of 

the super-excitement in certain parts resulting from depression in others, may 
occasion universal derangement, and consequently fever." 

Professor Eberle says : 

The causes of fever are generally divided by pathologists into two va- 
rieties, the predisposing and the exciting. They are all those external 
and internal causes which tend to lessen the power of vital resistance to 
the influence of morbid agents. The latter are those causes which excite ac- 
tual disease by the deleterious or irritating impressions which they make on the 
animal system. There exists, however, no absolute difference in the nature or 
character of these two varieties of morbific causes. 

The same agent or circumstances may manifest its influence on the animal 
economy either as a predisposing or exciting cause of fever, according to the 
degree of intensity with which it acts, or the previous condition of the system. 

Hence it is admitted that in proportion to the force of the cause applied to 
the system, so is the response either for weal or for woe, and we find that it is 
the received opinion that any cause predisposing in one may be an exciting 
cause to morbid action in another. Of most of the causes assigned by the 
writers we know but little, except from the localities where the malaria is found 
to prevail. We suppose them a deleterious something conveyed in the atmo- 
sphere, and generated by the influence of heat and moisture upon animal and 
vegetable matter. But it has been admitted that a cause with sufficient force 
to excite a morbid action by direct application or absorption has, in like manner, 
the power to impair the animal functions and to predispose one and excite an- 
other, and vice versa. 

This being clear, it Will be seen that the tendency of the viscera and fluids 
to gravitate, with the altered respiratory movements, are fruitful, predisposing 
and exciting causes of febrile action ; hence the attacks of fever do not all com- 
mence with diminished secretion of the skin and alimentary canal, though the 
cause may be the same ; which is owing to the intensity of the cause, and the 
amount of irritation or congestion of the capillary vessels, as was manifest in 
the two orders of attack of that frightful malady, the cholera, The force of the 
first was expended upon the extremes of the capillary vessels and nerves. 

In the second, the force was thrown upon the brain, which weakened the 
action of the heart, and produced semi^tagnation in the capillary vessels. In 
the former, the nervous twitching and spasmodic cramps, with profuse perspira- 
tion, were present from the commencement to the close ; in the latter, we had 
also profuse perspiration, or an effusion upon the external skin *nd internal 
mucous membranes, frequently terminating fatally without spasms. In some 
cases both sets of symptoms appeared to be moving conjointly. 

So I infer, in many cases of fever, owing to the deranged condition of the 
nerves and engorged capillary vessels and nerves that are essentially and prima- 
rily disordered. The first manifestation is suppressed or exalted action of the 
secretory vessels that are dependent upon the extreme terminations of the capil- 
laries. In like manner the first mark of convalescence is manifested in the ter- 
minating branches of the two tegumentary systems by the chmge in the secre- 
tions. But whether the nerves are the first or the second link in the chain of 



American Medicine and Surgery. 147 

morbid action, it has not been ascertained ; and it would be of little consequence 
in a practical point, if it were, as the relations of the two systems are so 
blended, that whatever disturbs the extremes of one deranges the other ; and, in 
like manner, whatever changes the quality of the blood, impairs the brain in its 
healthful functions, and entails a similar depression or exalted action upon the 
heart and arteries. So it seems that the extremes of these two systems and 
centres reciprocate in health and in disease. 

These systems are, therefore, the seat of primary irritation, whether it be 
from debility or congestion, from which arises morbid vascular action. Hence 
the opinion of some of the writers, that fever is a universal malady ; but it is 
obvious that the entire organism could not be in a state of disease , yet the func- 
tions may be more or less deranged through the influence of the morbid vascu- 
lar action established from the derangement in the extremes or centres. 

The causes, therefore, whether chemical or mechanical, are equally liable to 
establish fever, and, it seems to me, from the admitted facts, that one of the 
primary causes has been overlooked thus far. 

In the laborious search after causes, the liability of the viscera of the abdomen 
and the fluids to gravitate, with their influence upon the respiratory movements, 
upon the blood, and upon the general system, have been misapprehended by 
the profession. The anatomy of the organs and of the surrounding parietes, 
which are endowed by nature with a capacity to perform certain mechanical 
functions, clearly demonstrates their importance, and, if we look at the liability 
to local irritation upon the root of the mesentery, established by gravitation, we 
cannot but ask, What cause is better calculated to predispose or excite fever 
than the misplacement of these organs? Consequently, the direct cause of 
febrile disease, with a large class of the diseases to which we are subject, may 
be traced to such displacement. 

In the illustration of this position, we will suppose a case where the individual 
by too long standing becomes fatigued, the muscular system exhausted, and the 
small intestines having lost their natural support, gravitate to the true pelvic 
cavity. Now, what part is put upon the stretch ? Is it not the root of the 
mesentery ? And is this part not abundantly supplied with blood-vessels, nerves, 
glands, and secretory vessels ? 

What cause is, then, better calcluated fc) establish a morbid vascular excitement 
in the capillary system and nerves ? Again, if the first link in the chain of mor- 
bid action is discovered in the nerves, as contended for by some, have we not an 
irritating infpression ready to be conveyed sympathetically to the entire system 
by a primary focus of irritation ? And as it is known that the nervous and 
vascular systems are so immediately connected in every part of the body where 
these two systems are brought into a morbid condition — as they manifestly must 
be — by the displaced condition of the abdominal viscera, what is better calculated 
to produce fever than such displacement and weight upon the mesenteric blood- 
vessels and nerves ? It is evident, then, from the symptoms and character of 
the disease, that fevers depend upon a morbid action, commencing in the capil- 
lary vessels and terminating extremities of the nerves, or at their centres, giving 
rise to an accelerated action of the heart and arteries. Can it then be doubted 



!^8 Principles and Practice of 

that the irritation is produced from the weight, so far, at least, as the capillary 
system and nerves are concerned, and that the focal point from which the morbid 
vascular action is established in functional and inflammatory fevers, is the 
consequence of this deranged condition ? Look at the mental and muscular 
languor— the pains in the loins and lower extremities— the morbid sensibility to 
low temperature— the irritablen :ss of the system, and the desponding weakness 
of the intellectual powers, so universal in febrile disease, and ask, Is not this 
unequivocal evidence of the prevailing derangement of the capillary vessels and 
nerves of the abdomen ? Furthermore, look at the influence of the depressed 
condition of the abdominal contents upon the action of the diaphragm, with the 
loss of power in the muscles subservient to respiration, and the effects produced 
upon the blood, which leaves a superabundance of carbonic acid that is carried 
to the brain, and produces the train of diseases so fully described by systematic 
writers from a weakened action of the heart. Then contemplate the effect of 
the black blood upon the brain and its influence upon the heart, and ask if it is 
not more than probable that the cause of fever is connected with local irritation 
at the root of the mesentery, and with the obstructed bloodvessels, and the 
consequent congestion of the capillaries from obstruction, and the tendency of 
the fluids to gravitate ? 

From the history of the causes of febrile disease and their effect upon the 
animal economy, with the power of the organs to resist the surrounding causes 
so long as the general harmony is preserved, and with the symptoms of dimin- 
ished or increased action of the exhalents and secretory organs which terminate 
upon the internal and external surface, it is evident that the febrile agents 
uniformly derange the functions of the two'systems by establishing an accelerated 
morbid action, or a diminished action, amounting to the same morbid results. 

In the former, the disease is called into action by an agent of sufficient power 
to derange the action of the two systems, giving rise to violent reaction, frequent- 
ly of a malignant character. In the latter order of attacks, the system is 
exhausted in struggling with a distinct cause, or fixed point of irritation, until 
vital resistance is overcome and morbid action established— constituting the 
grade of fever called typhus, or typhoid as it is observed in the initial state. In 
the premonitory stages, we have various symptoms, such as loss of appetite, a 
furred or smooth tongue, disturbed slee"p, with a harsh, dry skin, irregular bowels, 
with lassitude, pains in the bones and extremities, slight headache, feelings of 
heat and cold, with many anomalous symptoms. 

By examining the symptoms as presented by the patient, it will Oe found that 
the altered condition of the secretory system, with the morbid sensibilities that 
are manifest, and the derangement of the digestive organs, heart and arteries, 
have been produced from an impression made upon the vascular or nervous 
system ; whilst in some, perhaps from the same cause, the nervous symptoms 
take the lead of vascular action, and in others, the two systems are simultaneously 
deranged, which brings on nervous and vascular action conjointly, thus making 
the compound order of fever referred to by the writers. But of the symptoms 
referred to, no one is so uniform as the diminished or exalted actions observable 
in the emunctories, which establishes the fact that the two systems, at their 



American Medicine and Surgery. 149 

extremes or centres, are invariably the first deranged and the first to show the 
returning- signs of health. By these convictions, my practice for twenty years 
has been governed, and has resulted in treating almost every grade of fever with 
more than usual success. After a conviction of the truth of the theory, my 
practice was simplified from the diagnosis being easily made out by the altered 
conditions of the secretions of the two tegumentary systems which freed me 
from the hap-hazard practice so frequently met with. To be skilled in diagnosis 
requires close and persevering observation, aided by a correct knowledge of 
anatomy, physiology, and the symptoms arising from the pathological condition 
of the organism, taken in connection with the age, temperament, climate, habits? 
hereditary predisposition, and character of the predisposing or exciting causes. 

Having thus given a brief outline of cause and effect, I now proceed to the 
doctrines in relation to the character of febrile disease. 

1st. Fever is not a disease, but a condition of imperfect reaction, a salutary 
effort of nature to eliminate or repair ; an effort to free the system of some 
morbific agent. 

2d, The first part impressed by the febrile agent, is that of the capillaries in 
some, and the nerves in others, or the two conjointly, either of which affect the 
other simultaneously. 

3d. The morbid vascular action may be established by a depressed or acceler- 
ated movement of the two systems, from direct irritation applied either chemically 
or mechanically. 

4th. The morbific causes act upon the two extremes or centres through the 
external or internal surface, and are conveyed to the entire system by a morbid 
molecular action, which extends to the entire system, through the capillary 
vessels, or sympathetically by the nerves. 

5th. The remote and exciting cause of fever is liable to produce congestion, 
irritation or inflammation. 

6th. Loss of balance between the capillary terminations upon the two tegu- 
mentary systems, by local determinations of the blood, is one of the strongest 
characteristics of fever, which is manifest in the initial stages by the altered 
functions manifested by chilly sensations aad changes in the secretions. 

7th. Morbific agents are not permitted to enter the general circulating mass of 
the fluids until the vital force is overcome, farther than the vessels that convey 
the limpid fluid, and they are frequently rejected by nature at one of the pro- 
visional outlets. 

Having thus given a summary of the observations collected from medical 
authors, clinical pursuits, and post-mortem examinations, in relation to the 
causes and effects of febrile disease, with my convictions as to the part of the 
system first impressed, and the universal symptoms, observable in all, of the 
altered condition of the secretions of the two tegumentary systems, I will now 
proceed to the classification of fevers, and for convenience I shall divide them 
into two classes— idiopathic and symptomatic, To the first belong all that class 
of fevers arising from malaria, miasma inhaled into the lungs or taken into the 
stomach through the saliva. To the second, or symptomatic, all which arise 
from disease or local injury to some part. 



150 Principles and Practice of 

IDIOPATHIC FEVER. 

CAUSES OF FEVERS. 

The causes of fever are either predisposing or exciting. Any thing that debili- 
tates or impairs the tone and existing power of the nervous or muscular 
system, may be denominated a predisposing cause of disease, as excessive phys- 
ical or mental exertion, protracted grief, anxiety and fear, chagrin, disappoint- 
ment, ill-ventilated abodes, improper food, insufficient clothing, over-indulgence, 
filth, etc. The exciting causes induce fever by a direct impression, as miasmata, 
contagious and epidemic effluvia, noxious gases, vicissitude of temperature, at- 
mospheric and electrical influences. The exciting causes do not operate so as to 
produce fever, unless the system is prepared or rendered susceptible to their 
influence by debility or some other predisposing cause. 

Hence the importance of sound physical culture, a rigid avoidance of all those 
things which can impair the normal integrity of the organism , a proper system 
of physical education, a correct system of dietetics. Idiopathic fevers have been 
classified under the following general divisions : Ephemeral fever — those 
which arise from slight temporary causes, and which terminate spontaneously 
when the exciting cause is withdrawn. Malarial fever, originating in malaria, 
a specific form of disease. Intermittent, remittent, continued and eruptive 
fevers. In these fevers there are certain peculiar characteristics, which distin- 
guish them respectively from all other maladies. But we never find two cases 
of the same type running precisely the same course, or presenting the same 
symptoms, Climate, age, sex, temperament, habits, etc., modify the character 
of each case. 

The course of a fever varies during its progress ; consequently there are some 
arbitrary divisions spoken of, but which by no means can be relied on ; for 
some fevers run their course without the supervention of these stages. 

They are as follows : the forming stage, cold stage, hot stage, sweating stage 
collapse. This is merely artificial, facilitates description. 

CRITICAL DAYS 

Are those in which a fever always has a tendency either to abate or become 
exacerbated, and were first observed by Hippocrates, and since have been fully 
shown to exist. According to Hippocrates, the critical days are the 3d, 5th, 
7th, 9th, nth, 14th, 17th and 20th, or, as some commentators declare the 21st, 
and since have been added the 27th, 35th and 42d days. The vigor of our 
practice is rather unfavorable to the clear manifestation of these crises. 



EPHEMERAL FEVER. 

Ephemeral fever is characterized by increased frequency and strength of 
pulse, with heat of skin, headache, thirst, and white, excited tongue ; termina- 
ting in perspiration generally within twenty-four hours. 

It is of frequent occurrence in this country, and is the slightest as well as sim- 
plest of all primary febrile disorders, and is so named from its seldom lasting 
longer than a single diurnal revolution. 



American Medicine and Surgery. 151 

Causes. — It is often difficult to discover any unequivocal cause for an attack 
of ephemeral fever. 

It effects chiefly children and young persons, and frequently seems to be ex- 
cited by the atmospheric vicissitudes during the irregular weather of the spring 
months in temperate climates. Excessive muscular and mental exertion, from 
prolonged exercise, or intense study ; exposure to sun, the intemperate use of 
alcoholic drinks ; disorder of the digestive organs, from repletion, or the nature 
of the ingesta or congestion of the liver, or a vitiated condition of the secretions 
of the primse vise, are all capable of producing an attack. The febrile condi- 
tion, often excited in puerperal women on the first secretion ul milk, has, by 
most writers, been classed under this head. 

Symptoms. — In the acuter form of ephemeral fever the invasion is generally 
sudden, the attack commencing with a chill, but in mild cases there are lassi- 
tude, yawnings, with a feeling of irritation, or excitement. These symptoms, or 
the initial chill when occurring, are soon succeeded by heat of skin and cepha- 
lalgia. The face is flushed, and animated, but the expression is natural ; the 
pulse is frequent, strong and full ; there is frequently pain in the small of the 
back, with a sense of great weariness and soreness in the limbs, the thirst is 
intense ; there is no appetite ; the tongue is white ; the papillae enlarged, the 
mouth is dry, with a bad taste, and the urine scanty and high colored. The 
skin, though hot. is usually soft. In children and in some women when the 
attack is severe, slight delirium may supervene for a short time. Exploration of 
the chest and abdomen discovers no lesion of the contained organs. These 
symptoms with restlessness, languor, want of sleep, and general uneasiness, 
having lasted for six, twelve or eighteen hours, the fever begins to diminish ; 
the skin becomes moist ; the urine more copious, and depositing a sediment, 
and the free perspiration occurring, the attack subsides within twenty-four 
hours, though occasionally it continues for several days, assuming the charac- 
ters and type of Inflammatory fever. Sometimes the patient becomes listless 
and feverish on the following day ; does not feel disposed to quit his bed ; and 
passes an uncomfortable day, with slight febrile exacerbation towards evening. 
After a good night's rest, however, he usually awakens refreshed and well. 

Diagnosis. It is often extremely difficult to decide, at the outset of an at- 
tack, whether it is a case of ephemeral, periodic, or continued fever. The ab- 
sence or presence of the causes just enumerated, may assist our inquiry. 
Whilst the non-occurrence or insignificance of the initial chill, and the continu- 
ation of the fever beyond six or eight hours, will often enable one to distinguish 
it from intermittent fever ; the amount of vascular excitement, the slight de- 
pression of the nervous powers, and the very transient duration of the premoni- 
tory symptoms, will serve to distinguish it from the more serious varieties of fe- 
ver. 

Prognosis. The prognosis is of course favorable, but it should be borne in 
mind that sometimes the disorder is prolonged beyond the diurnal period and 
assumes a more serious character. 

Treatment. — Confinement to bed, abstinence from food, and demulcent 
drinks are often all that is necessary for an attack of ephemeral fever, whose 



152 Principles and Practice of 

tendency is towards a favorable termination, and which, indeed, requires little or 
no treatment. If, however, the disorder has followed exposure to a hot sun, 
and there is much vascular excitement, with cerebral symptoms, an emetic of 
comp. powder of lobelia may be advisable together with a mild purgative, and 
cold applications to the head. If the attack be subsequent to a debauch, 
the stomach and bowels should be freely evacuated. Where the stomach is ir- 
ritable, a tablespoonful of syr. rhei et potass, should be administered — to be re- 
peated every four hours. When the skin is dry diaphoretics should be adminis- 
tered. 

]p&— Fid. ext. Asclepias "} a a 

" ," Serpentaria J ss 5 

Sig. — 20 drops every two hours. Cold water as a drink when wished for. 
If the patienc is debilitated then direct — , 

^t— Fid. ext. Populus Trem ") aa 



Hydrastis Can J i 5 

Cornus Florida i O 



Holland Gin 

Sz'g. — i Tablespooriful before each meal. 



MALARIAL FEVER. 

Of all fevers this is the most extensively known, and vastly prevalent in our 
country, and it would seem that there are some indispensable conditions neces- 
sary to the development of this fever — such as an elevated temperature, decay- 
ing organic matter for supplying the material for the generation of this poison- 
ous agent, whatever it may be ; surface water which impregnates the air with 
vapor, promoting those chemical actions in certain soils, generates malarious ex- 
halations, favors decomposition of a luxurious vegetation, produces animalcule 
or microscopic plants ; and thorough evaporation and condensation produces 
electrical and chemical changes. In sections of country where this marsh or 
paludal poison exists in a high degree, we have an imperfect physical develop- 
ment, an engorgement of the abdominal viscera, more especially the spleen ; 
general inertia and torpor. All the physical, intellectual, and emotional facul- 
ties are depressed from the action of the poison, if the atmosphere holds a 
large quantity of the specific poison, a short time may elapse before the dis- 
ease is developed ; if the quantity is smaller it will take a longer period to excite 
the malarial action. If the fever is once established it may assume any one of 
the various types usually observed. If the atmosphere is strongly saturated 
with miasm the most trifling exposure to vicissitudes of temperature or exhaust- 
ing exercise will develop true intermittent fever. If there is less malaria in the 
atmosphere, but other causes combine with it to derange the ordinary opera- 
tions of the different organs, the disease has less of a chill and more of the fe- 
ver. If the amount of malaria is still smaller, there may be only a slight remis- 
sion, no intermission of the fever. 



American Medicine and Surgery. 153 

If the malaria exists in a greater or less degree, aided by other causes of dis- 
ease, the remission may be scarcely perceptible, and then the case may be con- 
sidered a continued fever. 

l If these various forms of malarious fever are improperly treated or tampered 
with they may merge into a low form of typhoid ; and if the patient is greatly; 
prostrated or exhausted by any cause, we may have it assuming a congestive 
form. 



INTERMITTENT FEVER. 

This fever consists of a succession of paroxysms, between each of which 
there is a distinct intermission, or subsidence of the febrile stage, called apyrexia. 
The period from the beginning of one paroxysm to the beginning of another, is 
called the interval; and that from the end of one to the beginning of another 
the intermission. The paroxysm recurring daily, the intermittent is called 
quotidian, every other day, tertian, and when the attack reverts only once in 
three days it is called quartan. The attacks are said to recur sometimes much 
more seldom, e.g , once a year. I am convinced that t:,e disease having ceased, 
has a tendency to reappear on the 8th, 15th, and 22d of its cessation, as well as 
semi-annually, or annually. The types are sometimes complicated. There may 
be, for instance, the double tertian with two paroxysms, every other day; or 
with a paroxysm every day the alternate paroxysms corresponding. These com- 
plications are rare. Of all the types, the terti?n is most frequent, and the quo- 
tidian next. The quartan most frequently arises from neglect or ill manage- 
ment of the other varieties. Commonly the quotidian occurs in the morning, 
the tertian at noon, and the quartan in the evening, Each paroxysm is divided 
into the cold, hot and sweating stages. 

THE COLD STAGE 

Supervenes by the extremities feeling cold and contracted ; the surface pale and 
shrunken, rough; diminished sensibility; a sensation of cold along the spine, 
which diffuses itself over the whole body ; then tremors, chattering of the teeth, 
nails purple, the skin the appearance of goose flesh ; respiration labored, rapid 
and imperfect, oppression over the region of the heart, countenance pale, leaden 
earthy or livid, shrunken, and expressive of anguish, sometimes vomiting, with 
urgent thirst, and frequently copious discharges of pellucid urine. The mind 
is also irritable and childish. When the natural powers are feeble, or the force 
of the attack is overwhelming, the blood determined upon the internal organs 
remains. The cold stage having continued from half an hour to an hour, or 
sometimes longer, reaction succeeds, inducing the 

HOT STAGE, 

Hot surface, flushed face, violent n ^adache, anxiety, stomach generally disor- 
dered, bowels unmoved, urine red. Pulse slowly becomes voluminous and ve- 
hement. This state continuing from three to twelve hours, the 



154 Principles and Practice of 

SWEATING STAGE 

Supervenes with great relief. The functions are restored to a state compara- 
tively healthy. The urine, in the former stage clear and red, is now a little tur- 
bid, and deposits a whitish sediment, unless a crisis is about to take place, when 
the sediment is lateritious, or brick dust like. 

DURATION. 

Twelve hours are given as the ordinary duration of a tertian, though it may 
extend to eighteen. Each of the stages has sometimes been absent. Sweating 
has been substituted by discharge from the kidneys. All the stages of a tertian 
are more severe than those of a quotidian. The quartan is in severity like the 
tertian, but is distinguished for slightness of perspiration. The case has some- 
times been restricted to one part of the system — the limbs, for instance. 

Intermittents are sometimes masked by other diseases, which fact it is of im- 
portance to detect. 

SYMPTOMS OF THE CONGESTIVE FORM. 

Coming on with debility, the chill is either violent for a short time, or is very 
slight, or is alternated with feverish flushes, or very speedily heavy congestion 
supervenes in one or more viscera. Such an attack is easily followed spontane- 
ously by a normal hot or febrile stage. Continuing from six to eighteen hours, 
the coldness is succeeded by clammy or dewy perspiration. 

The intermission is imperfect, and the succeeding paroxysm appears at an 
earlier hour. The pulse is nearly extinct, or low, hobbling, full and compressi- 
ble, the tongue moist and milky, skin cold and damp, with sometimes a very 
unequal temperature. The engorgement of the brain and lungs occasionally 
amounts to apoplexy. Cases occur in which there is little consciousness of dan- 
ger, and little apparent suffering, and in which the patient may continue to walk 
about the house, that are prone to terminate suddenly in a swoon. Reaction, 
however, does sometimes take place in force sufficient to accomplish a recovery. 
In other instances the force of the disease seems to be expended on the primae. 
viae. Here there is great gastric disorder, jacitation, a moist tongue, with a dis- 
position to syncope. At times, without any chill, fever or prominent symptom, 
the patient is seized with meteorism, copious discharges from the bowels, some- 
times emesis of a thin turbid fluid, and occasionally cramps of the muscles. 
Coming on in the same way, but without disturbance of the alimentary canal 
there may take place an excessive and debilitating cold sweat. In all these cases 
reaction is rare, but taking place, if moderate, it produces a low, congestive 
fever. If it be forcible, the fever is of a higher grade, and there is a peculiar 
determination to the brain. 

THE GASTRIC VARIETY. 

The majority of our autumnal intermittents are of this character ; they are at- 
tended with strong marks of irritating matters in the primae viae ; there is nau- 
sea, bilious vomiting, bitter taste, weight and fullness in the epigastrium, great 
pain in the forehead ; foul tongue, quivering of the under lip ; countenance and 
white of the eyes tinged with yellow ; urgent desire for acid drinks. 



American Medicine and Surgery. 155 

MALIGNANT INTERMITTENTS. 

Rapid in their course — sweat, in the third stage, generally very copious and 
fetid ; haemorrhages from the nose, bowels, gums, etc. ; petechia ; and other 
symptoms denoting malignity. 

APYREXIA. 

During the apyrexia the pulse is not right, and there is disorder of the alimen- 
tary canal. Indeed all the secretions and excretions are vitiated. Mind and 
body are both deficient in tone. 

The apyrexia is marked also by sallowness of complexion, uncomfortable feel- 
ings in the hypochondria, or head, with an increased sensibility to cold. 

In the graver varieties the apyrexial disorders are still greater, and the tendency 
of one paroxysm to encroach on another, leads to the formation of remittent or 
of low continued fever. 

CAUSES. 

Remote — Marsh Miasmata. — The decomposition of vegetable matter by the 
aid of solar heat and moisture, is the only condition necessary to develop the 
morbific principle. , 

Excitng, and not, as has been supposed, predisposing causes also, are ex- 
treme heat of the atmosphere, indiscretions in diet, accumulations of bile, etc. 

Confounding intermittent with hectic, some of the late writers attribute it to 
a variety of local irritations. It occurs at times as an epidemic ; and so occur- 
ring, is apt to be more malignant, or mixed and ambiguous in character, requir- 
ng, therefore, a close diagnosis. 

No age is exempt. 

DIAGNOSIS. 

The intermission is the most distinctive trait. The time of the year, expos- 
ure of the individual to miasma, and the symptoms of a developed attack, will 
assist in the diagnosis. In pathology it most resembles the remittent, but in 
external physiognomy, hectic fever. Intermittent and hectic thus differ : 

1st The paroxysms of hectic want that agony in the spine and limbs, so char- 
acteristic of intermittent. 

2d. The paroxysms of hectic are seldom uniform for any number of days in 
succession, and after a short time, may come on at any hour of the day or 
night. Two paroxysms occur mostly in the twenty-four hours. 

3d. The paroxysm of hectic is often destitute of the. chilly and sometimes of 
the other stages. 

4th The sweating stage of hectic does not always afford relief ; on the con 
trary, chills and flushes may come and go at the same time. 

5th. The flash of the cheek in the hot stage of hectic, is circumscribed and 
peculiar. 

There is no headache, but the joints of the lower extremities, apt after a time 
to be swollen, become in the hot stage extremely painful. 

6th. The pulse in hectic does not subside with the paroxysm, and in every res 
pect is the apyrexia less complete. 



156 Principles and Practice of 

7th. The tongue in hectic is clean, florid and polished ; in intermittent?, is cov- 
ered with a whitish or yellowish fur. 

8th. The alimentary canal is healthy in hectic, but the reverse in remittent. 

9th. The urine in hectic is usually turbid during the paroxysm, and clear in 
the intermission, but reversely in intermittent. 

10th. The rnind in hectic is cheerful, while it is the opposite in intermittent. 

PROGNOSIS. 

Tertian is the most manageable type, the quotidian being apt to degen^ate 
into remittent or continued fever. Favorable signs are a complete chill, which 
foretells an efficient reaction ; the retardation of the paroxysm ; cleaning of the 
tongue ; bilious or dark, tarry and offensive stools, lateritious sediment in the 
urine; and scabby eruptions about the mouth. The unfavorable signs, are the 
premature appearance of the paroxysms, and complication with other disease. 
The case will be more intractable also in proportion to its duration, which re- 
sults as well from the force of habit, as from the disorders of the. chylopoietic 
and other viscera. A violent paroxysm, when simple is not the most dangerous, 
but frequently proves the final attack. "The disease is dangerous to the infirm. 
Children are easily cured. The intermittent may terminate by a conversion 
into remittent or continued fever, or it may run into a chronic state and by long 
protraction derange the organs. In this latter way it lays the foundation of 
other diseases — as certain affections of the heart or lungs, or inflammation, or 
congestion of the abdominal viscera, with jaundice, and especially dropsy. The 
nervous system may also become deranged, and particularly with neuralgia. 

Death occurring suddenly during the cold stage of a paroxysm, it is usually 
from engorgement of the viscera of the c,reat cavities ; occurring during the hot 
stage, it is from convulsions arising from excitement of the brain or spinal mar- 
row. The sweating stage is scarcely ever fatal, except in malignant and conges- 
tive cases. 

POST MORTEM. 

Death happening in acute cases in the cold stage, the chief if not only appear- 
ance is that of engorgement in one or more viscera. * 

Death happening in the hot stage of an inflammatory attack, or after a series 
of paroxysms, phlogosis is displayed in the brain, its meninges, or those of the 
spinal marrow, in the pulmonary apparatus, or in the abdominal viscera. 

Congestive cases, death occurring at any stage, display immense engorge- 
ments and traces of weak inflammation. In chronic cases are revealed all kinds 
of organic depravation of the abdominal viscera, with frequent hydropic effu- 
sion. 

PATHOLOGY. 

From the symptoms in the cold stage, it is manifest that the internal capillary 
vessels are congested, whilst the external are left with a proportionate deficien- 
cy, which is obvious from the cold, pale, contracted condition of the surface. 
Then is not this chill, etc., the consequence of the want of balance between the 
internal and external capillaries, and the change produced upon the nerves ex- 
ternally, the consequence of a deficiency in the vital fluid and upon the nerves 



American Medicine and Surgery. 157 

internally of a superabundance ? The functions on the one hand being dimin- 
ished while on the other they are morbidly exalted. 

Is not this view in accordance with th 1 anatomical arrangement of the two teg- 
umentary systems— with the capillary vessels and nerves terminating upon the 
internal and external tunic, and -with their reciprocal and physiological func- 
tions ? In all diseases we find irritation, congestion, or inflammation, in pro- 
portion to the loss of balance in the two surfaces producing a chill. The ap- 
proach is at first discoverable at the extremities, by the blue appearance under 
the roots of the nails, which is soon followed by yawning and stretching, with a 
sensation of cold, alternating with flushes of heat, until rhe cold becomes pre- 
dominant throughout the system. After which a spasmodic action prevails un- 
til the reaction gradually forces the heat from the centre to the surface; and 
after the occurrence of the hot and cold stages, the two capillary surfaces are 
balanced, the secretion internally and externally augmented, leaving the patient 
for twenty-fcur or thirty-six hours apparently without disease. Thus it is evi- 
dent that the chill is the consequence of periodical congestion, and also the hot 
and sweating stages, which are an effort of nature to restore the loss of balance 
between the surfaces, and free herself from the irritating cause. 

In simple intermittent, the periodical congestion is upon the capillaries of the 
liver, stomach, and bowels. 

TREATMENT OF THE PAROXYSM — INFLAMMATORY FORM — COLD STAGE. 

To overcome the chill, we place the patient in bed, cover him well, make hot 
applications to the lower extremities, and administer warm beverages. The 
mischief, however, taking place principally in the coid stage, should it be protract- 
ed, or the prostration be considerable, we resort to more efficient measures. For 
this purpose I have used c&psicum and xanthoxylum with the best results. 

9^— Tr. Capsicum 5 i. 

Fid. ext Xanthoxylum 5 iv. 

Mix. — St'g- — 15 drops every half hour in warm water. Friction to the spine 
and a capsicum poultice over the epigastrium. An emetic of comp. powder of 
lobelia. 

Tfc—Vvl. Lobelia 3 iv. 

' ' Sanguinaria 5 iii. 

" Symplocarpus 5 iii. 

" Ipecacuanha S iv. 

" Capsicum 5 j. 

Sz'g. — One-fourth drachm in warm water every 15 minutes until free emesis is 
produced. The substitution of cold for hot applications has sometimes succeed- 
ed by reviving cerebral and nervous energy. 

HOT STAGE, 

The indication here is to promote sweating. 

Emetics. — These may be prescribed when the stomach is irritated by bile or 
other matter. Follow with an alcoholic vapor bath. Put the patient in bed, 
cover lightly, and administer diaphoretics. 



158 Principles and Practice of 

P-Fluid ext. Asclepias Tub ^aa. 

" " Se-pentaria ) iv 5 

Sig. — 20 drops in warm water once in two hours. The agents usually relied 
upon in our system of practice are : quinine, prussiate of iron, podophyllin, 
berbeerine, lobelia, eupatorium per, cornine, salacine, chinodine, capsicum, san- 
tonine, cimicifuga, populus senecio, etc. 

The best time to give the remedy is at the expiration cf the paroxysm, or sev- 
eral hours before an expected attack, and it must be repeated at regular inter- 
vals and after the disease is interrupted, it is advisable to keep up the action of 
the remedy at proper intervals. The best combination is the following: 



fy— Sulphate quiuine 



) aa 
) gr. x 



Prussiate of iron 

Capsicum " Ui 

Eupatonum-per " iii mix 



Make six powders, one every two hours : 

^fc— Berbeerine ) aa. 

Quinine ) 

Prusiate ferri ) gr. x mix 

Make six powders as above, or 

9?— Chinoidine 1 

Caj>sicurn ." ! 



aa. 



Santonine i „_ YYV 

Cornine J gr- x * 

To make three grain pills, one or two every hour, and after it is broken keep 
up the action of some remedy, as Huxham's tincture cinchona, or syrup boneset 
and salt for a week or ten days. All through the case maintain regular secre- 
tion and excretion by the proper remedies, and if there is enlargement of the 
spleen apply a capsicum plaster and give cinchona. If the patient is of a high 
bilious temperament, a weak infusion of eupatorinm perfolialum is an excellent 
remedy. If the type is of the quotidian and tertian, combine the anti-periodic 
with xanthoxylum, and more especially is this remedy indicated if the patient is 
intemperate or of sedentary habits. If the type is the quartan and a female 
with deranged menstrual function, give cimicifuga and senecio. The only pre- 
paration of iron that is admissible in the treatment is the prussiate. 

The adjunct treatment with the remedies and their indications: Lobelia is given 
with marked benefit, where the patient is wretched and obstinate ; asclepias 
where there is violent fever ; lactuca where the head suffers, pulsations of the 
carotid, red injected eyes ; capsicicm in the phlegmatic temperament, flabby* 
mucus constitution, cimicifuga acts largely on the brain and nerve centres, and 
acts in some cases as well as quinine. 

CONGESTIVE FORM. 

The treatment in the congestive form does not differ materially from the 
foregoing. When the system fails to react we have venous congestion, and this 
may bring about congestion of brain, apoplexy, or coma. Emetics, alcoholic 
vapor bath, capsicum, or mustard to the stomach, neck and extremities — any 
thing calculated to get up reaction. Where we have much disturbance of the 
bran we would give fuli dose of cypripedium with asclepias added, say 



American Medicine and Surgery. 159 

9;— Fid. ext. Cypripedium i "J 5 i 

" " Asclepias tub J 5 ss. 

Sig. — One-half teaspoonful, and repeat in one hour if not relieved. This is 
preferable to the opium of the old school. Cases occur, also, where there is 
dangerous collapse vnthout extreme concentrations of blood. These cases are 
to be managed by external warmth, cordial stimulants, capsicum and lactuca. 
Examples, moreover, of the disease, are met with, where the whole force seems 
to be expended on the alimentary canal, promotive of incessant vomiting and 
purging. 

Here use neutralizing mixture and stimulants. The sweating being excessive 
the most effectual treatment will be warm saltwater baths, and next a stimulating 
liniment to the epigastrium, with dry frictions and a lotion to the surface of strong 
solution of alum in brandy, or the hot air bath. As the system emerges from 
these states of prostration, fever may ensue which is to be treated according to 
its character. 

TREATMENT OF THE APYREXIA. 

Diversified as are anti-intermittent medicines in other respects, they all 
concur in deriving their curative power in this diseas;, from their adaptedness 
to subvert the disposition to a renewal of that gastric irritation, which usually 
constitutes its inceptive movement. 

Before the commencement of tonic remedies, the system should be prepared 
for their use. In consequence of a neglect of this preparation, the difficulty of 
cure is enhanced, the intermittent-is in danger of being converted into a remit- 
tent or continued fever, relapses are common, with serious organic derange- 
ments. 

These preliminary measures are emetic and cathartic evacuations. The 
former seem, by breaking up trains of morbid association, to possess in them- 
selves an anti-periodic power. A vast number of other remedies have been 
r ecommended, stimulant, tonic, or astringent. Indeed, whatever powerfully 
affects the physical or mental constitution, has a tendency to destroy the inter- 
mittent. When we have congestion, it is important to prevent a second attack, 
and to ward off this commence, say eight hours before the expected attack, and 
give 

9;— Sulp. quinine J gr. xii. 



jgr. 



Pulv. capsicum ) " vi. 

Triturate and divide into four powders; one every two hours until the danger 
has passed. 

TREATMENT OF ABNORMAL MANIFESTATIONS. 

In intermittent developing itself merely on some organ, the eye for instance, 
or as a nervous disease, the treatment will be the same as in a normal presenta- 
tion. Intermittents being blended with a more serious disease, as dysentery, 
should be disregarded till the more urgent affections be cured. 

DIET. 

This should co-operate with the treatment, and be more or- less nutritious, 
accordingly. 



l6o .... Principles and- Practice of 

Intermittents, though some have attempted to prove them ti be salutary, 
should be cured as soon as possible. It is not true, moreover, that they have 
much tendency to cease spontaneously. 

The earlier, too, we commence with tonics, after theevacuant preparation, the 
better. 

Intermittents have a tendency to be revived every seven days. 

In anticipation of this, therefore, we should administer our tonic?, for three 
different periods. 

In consideration of the great disposition of the disease to return even when 
seemingly eradicated, all exciting causes ought to be avoided. If the patient do 
not emigrate from the miasmatic district he should be particularly careful not to 
go out in the morning without having first eaten, and should take daily doses of 
quinine and iron. The cold bath, or travelling, often succeed in preventing 
relapses. 

An attack being threatened the patient should go instantly to bed, cover him- 
self warmly and take an emetic. But as a preventive of a paroxysm of the per- 
nicious congestive intermittent, so much dreaded, the most efficacious appliance 
is a stimulating capsicum poultice to the epigastrium, so as to be fully drawing 
at the time of the expected accession. At this juncture also is to be given qui- 
nine and capsicum as before directed. 



REMITTENT FEVER. 

This fever bears a resemblance to intermittent in its cause and effects. It is 
a form of continued fever characterized by remissions. 

There is no cessation of the fever, simply an abatement or diminution. 

The period of remission varies from twelve to twenty-four hours, at the end of 
which time the feverish excitement increases ; exacerbation being often prece- 
ded by chilliness and rigors. The cause of this special type of fever is malarial 
and paludal poisons acting on an impaired or shattered nervous system. This 
form of fever varies much in severity according to the locality in which the poi- 
son is generated, in some sections being very mild, in others it acquires a bilious 
and malignant form and is very severe and fatal, hence there are many names 
for the fever, as remittent, bilious, or malignant. 

SYMPTOMS.— The paroxysm of remittent commences usually with chilliness, 
languor, lassitude, mental depression, a feeling of cold down the back and head- 
ache. To these sensations soon succeed febrile symptoms, constituting the hot 
stage, the prominent phenomena consisting of great heat of skin, severe head- 
ache and giddiness, often accompanied by delirium ; a frequent and full pulse ; 
a dry and furred tongue, nausea, and vomiting, generally of bilious matter ; 
sense of pain at the epigastrium, and tenderness on pressure, with signs of pul- 
monary congestion such as dyspnoea, a feeling of oppression at the chest, cough, 
and a livid color of the countenance. The urine is often scanty, high colored 
and loaded with lithates, but it is passed in increased quantities during the re- 
missions. 



American Medicine and Surgery. 161 

The remissions usually occur in the morning, and have a duration generally 
of ten or twelve hours. 

The principal exacerbation generally takes place towards the evening, and 
continues for the greater part of the night, though sometimes the paroxysm lasts 
tor twenty-four hours, or even thirty-six hours. The disease may run on for 
about fourteen or fifteen days, unless shortened by proper treatment, and then 
terminate rather abruptly in an attack of sweating, or its symptoms may merge 
in those of low fever. The period of convalescence is usually short unless some - 
organic mischief has occured, in which case considerable time may elapse be- 
fore a restoration to health is effected, the debility being kept up by night sweats 
sleeplessness, dyspepsia, hypochondria, neuralgia, jaundice, and even dropsy. 

Complications. — The extreme severity of some cases, the depressed condi- 
tion of the nervous and vascular systems with defective secretions, the great 
exhaustion at the termination of a paroxysm, collapse, convulsions, or delirium, 
passing into drowsiness and coma, cerebro-spinal meningitis, often with great 
gastric irritability, or with bronchitis, or with hepatitis, jaundice, diarrhoea, typhoid 
symptoms predominate. The chief causes of the complication are great de- 
pression of the nervous system, with powerful epidemic influences, malaria, im- 
proper treatment. As a rule, the fever either terminates in recovery in one or 
two weeks, or in some of its numerous complications. The diagnosis is impor- 
tant. A continued fever with distinct remissions, but when its complications 
take place, other morbid states supervene. 

Treatment. — The principal indications to be followed are nearly the same 
as in intermittent fever. Begin treatment with an emetic : 

#.— Pul. Lobelia (herb) ) aa. 

Pul. Eupatoriurn. Per ) 3 j. 

Sig-. — Steep a teaspoonful in a tea cup of boiling water and give one-half at 
a dose, and repeat every fifteen minutes until free emesis is obtained. This 
should be preceded with copious drinks of tepid water, subsequently an alco- 
holic vapor bath ; then unlock the bowels with some saline purge, as citrate of 
magnesia, or 

J^-Podophyilin gr. iv. 

Bi-tartrate potass >... 3 iii. 

Pul Capsicum gr. vi. 

Mix intimately and give one scruple every two hours until it operates suf- 
ficiently, then rest in bed, and the general treatment of fever at the same time. 
It must be remembered that as the febrile exhaustion is of longer duration, of 
greater intensity, than ; n intermittent, so that there is more fear of structural 
lesion of brain, liver, spleen, stomach, our object should be to control the fever 
effectually, so as soon as the emetic and cathartic have done their work, begin 

with — 

#— Fid . ext . Asclepias Tub ~) aa. 

" " Serpeutaria * j 5 iv. 

Dose. — Twenty drops every half hour until the excitement has completery 
moderated and the pulse has subsided to 72, headache and other symptoms 
11 



1 62 Principles and Practice of 

greatly ameliorated. Then begin with anti-periodic remedies to shorten or 
break up the exacerbations, as : 

~fy— Sulph . Quinine » — ") aa. 



Prussiate Ferri J gr. xii. 

Capsicum " viii. 

Mix. — Make sixteen powders. Immediately after the remission a powder every 
three hours, taking care to omit as soon as the cold stage sets in. At the next 
remission, we resort again to anti-periodics, and so on until it is certain that the 
febrile phenomena have entirely disappeared. During the febrile stages pro- 
ceed with emetic and cathartic, as above, follow with asclepias and serpentaria. 
If there be diarrhoea, give : 

Ifr— Syrup Rhei et Potass 3 iv. 

Fid. ext. Geranium Mac 5 j . 

A teaspoonful as indicated, with some stimulating applications over the ab- 
domen. The diet should be light and nutritious. The complications of remit- 
tent fever should be treated very cautiously. If there is much cerebral derange- 
ment, active purgatives, heat to the feet, keep the head cool. If there is low 
delirium or exhaustion, free stimulation and nourishment ; if cerebro-spinal irri- 
tation make its appearance, capsicum plaster to nape of the neck, internally cy- 
pripedium lactuca. 

In the interim give anti-periodics, as for instance : 

. ^t— Sulph. Quinine gr. xv. 

Scutellarin " x. 

Cypripedin " x/ 

Mix. — Make six powders ; one every two hours. As soon as the paroxysmal 
form of fever is removed, very little treatment is necessary. Tonics, as either the 
wine bitters, compound tincture tamarac, or hydrastia, should be given. 



BILIOUS FEVER. 

A form of remittent fever induced by depression of the liver. It is generally 
caused by eating carbonaceous food, alcoholic drinks, malaria 1 — by anything that 
will depress the liver. It is easily recognized by nausea, vomiting, brown 
coated tongue, yellow skin, and conjunctiva, coma. 

Symptoms. — There is a shock, a period of incubation, in which there is languor, 
lassitude, debility, nausea, vomiting, brown-coated tongue, yellow skin, pain, 
perhaps, over the region of the liver and shoulder, or there may be diarrhoea or 
constipation. In the treatment of this fever an emetic of the compound powder 
of lobelia, followed by suitable doses of the compound powder of podophylin 
to act on the liver ; an alcoholic vapor bath ; then rest in bed ; control the 
circulation with 20 drops of asclepias and serpentaria every hour. Diet, milk or 
farinaceous food. Stimulate the depressed liver with either podophyllin, or 15 
drops of dilute nitro-muriatic acid three times a day. As soon as the fever is 
controlled, establish convalescence upon tonics. 



American Medicine and Surgery. 163 

This form of fever requires very nearly the same treatment with the exception 
that the force of the poison seems to be spent on the liver, so there is more apt 
to be brown-coated tongue, nausea, vomiting, jaundice, diarrhoea and other 
bilious symptoms, a condition where leptandrin, nitro-muriatic acid, phosphate 
of soda, anti-bilious physic, and other remedies that stimulate that organ, should 
be given and the fever managed as above. 

Remittent bil.ous malignant fever, is a type that simple remittent sometimes 
assumes. The great heat, frequent respiration and pulse, jaundice skin, irritable 
stomach, with dark charcoal hue on the tongue, all indicate extreme prostration, 
with blood poisoning. Energetic treatment, as in the simple and bilious 
form. Antiseptics, as a tablespoonful of brewer's yeast in a glass of milk three 
times daily, or a decoction of wild indigo weed, or sulphite soda, to arrest the 
malignant tendency with powerful stimulants and antiperiodics. 

Bilious and malignant remittent requires in all cases energetic treatment. The 
emetic, the anti-bilious purge and alcoholic vapor bath, followed by rest in bed, 
sponging frequently, and full doses of diaphoretics every two hours, until the 
circulation is controlled, and then follow with quinine and prussiate of iron in 
doses to meet the conditions of vital depression and malignancy of the attack. 
The dose of the medicine must be in all cases in proportion to the condition of 
the locality, the virulence of the poison, the shock to the patient, and on no 
account must stimulants and antiseptics be spared. . 



CONTINUED FEVERS. 

YELLOW FEVER. 

This disease prevails endemically in tropic countries, having a compound 
origin arising from the effects of animal and vegetable miasm. f 

£ SYMPTOMS. 

Introductory. — Generally lassitude, stiffness of limbs, and uneasiness in the 
back, loins and calves of the legs. Soon after a sense of coolness, which is 
succeeded after many hours, or more speedily, by a dry, hot skin, dull, or acute 
pain of the head, darting through the eye-balls, injected eyes, and a countenance 
expressive either of fierceness or incipient drunkenness. 

Sometimes, however, the countenance betrays no change, or even a preter- 
natural serenity, or a look of great distress, with lachrymation, or a malignant 
frown, and the face is either leadened or bronzed, with a marble-like expression. 
The mind usually preserves a singular integrity throughout the disease, though 
there may be from the beginning indications of its aberration or weakening. 
Epigastrium tender, possessing often a burning sensation, with anxiety and 
oppression at the prascordia. The bowels usually maintain an obstinate torpor, 
the tongue is little changed, or white and furzy. 

After the first twelve /tours. — An exacerbation of the fever. Evidence of 
undue accumulations of blood in one or more of the viscera. Deep sighing, 
nausea, retchings of mucus, or glairy albuminous matter. Vomiting seems to 



164 Principles and Fr act ice of 

take place by an irregular, convulsive movement of the diaphragm. Wretched- 
ness ; the tongue milky, broad and furzy, or florid, or of a fiery redness, or 
perfectly natural. 

Not*arrested, the symptoms now rapidly become worse. The eyes assume a 
dirty yellow color ; circulation more irregular, the carotids, in particular, pul- 
sating strongly ; the surface damp or sweaty, with a state of skin approaching 
to oedema, and of a yellow hue, though this last occurs only in cases of extra- 
ordinary malignity ; frequently, sore throat ; difficult deglutition, and, sometimes, 
paralysis of the extremities. 

Towards the close of the third day. — Not unfrequently an apparent abatement 
of most of the bad symptoms. Soon afterwards, however, supervene almost 
unquenchable thirst and discharges usually of the dark, flaky, granular matter 
called black vomit. Contemporaneously occur a reduction of temperature and 
decrease of vascular action and muscular power, though the last may be fully 
retained to the end. Feeble pulse, cold, colliquative sweats, involuntary diar- 
rhoea of matter like black vomit, haemorrhages of dark blood, low delirium, with 
coma ; laborious respiration, singultus, collapsed countenance, muddy eye, tumid 
abdomen, occasionally sallow or livid skin. 

Sometimes, however, there is an anomalous absence of many of the derange- 
ments which we have just described. The patient is unconscious of disease, 
and, without manifest delirium, insists upon going out and resuming his avoca- 
tions. But even here the 'peculiar countenance, the deep sighing, and tender 
epigastrium, distinguish the disease. This serene state will in two or three 
days terminate by a sort of swooning away, or will become more developed by 
the supervention of black vomit and other characteristics. In other case.-, 
death takes place without the slightest premonition, and with the suddenness of 
a blow. 

Sometimes the disease is shown only by pain in the toe, or some other anoma- 
lous part. Priapism has been also remarked as the only manifest affection. 
Also in the female is apt to occur pruriency of the pudenda^ The epidemic 
seems to select for the force of its attack the part most predisposed. Displayed 
generally in the epigastric region most forcibly, it may fall on any of the lower 
viscera, or the lungs, or the cerebral, muscular, or nervous system, the affection 
of which may be so preponderant as to obscure the real disease. 

CAUSES, 

It may be generated from the materials which are contained in the holds of 
ships, and is never carried by germs in the air. But thedistempered atmosphere 
of a port at which the fever is raging, may be confined in the hold of a vessel 
which is hermetically sealed, until the hatches are opened in another port. 
During this time the crew will not, of course, be subject to the disease, though 
they may acquire it at the opening of the hatches. Likewise when the miasm 
is generated from a putrefying cargo, the crew may be exempt until ihe hold is 
opened. It is equally certain, however, that the same kind of miasm may be 
evolved by the putrefaction of domestic filth in certain positions, as was evinced 
by the fever in Philadelphia, in 1805 ; in Baltimore and New York; in Savah- 



American Medicine and Surgery. 165 

nah, Ga., in 1854— 1876; and in Memphis, Tenn , in 1877, and, in fact, all the 
cities of the United States where yellow fever has appeared, have been found 
in a most neglected, filthy condition. 

Whether exhalations from fihh, local or imported, will be productive of this 
fever under all circumstances, remains to be determined. Reasons thef e are, 
however, to suspect that the tendency to spread is enhanced by high tempera- 
ture steadily preserved. We may suppose also that the generation of the miasm 
is dependent on a certain constitution of atmosphere. 

Fevers do arise in situations where none of the materials of miasmata exist. 
The yellow fever here, as in other places, avoiding, as it were, foul and dirty 
wharves, has broken out on the neatest. But this may be, perhaps, explained 
on the supposition that where the surface is dry and clean, there are accumula- 
tions below, from which, through the crevices, the poisonous miasm escapes. 
It may be, moreover, affirmed that the fever has generally appeared and raged 
to the greatest extent on wharves recently made, and filled up with the filth of 
the streets and argillaceous soil of cellars. 

Yet, contrary to all this, has it been affirmed that yellow fever is of contagious 
origin. By contagion, it is presumed, is here meant what the word legitimately 
signifies, — a virus generated in one individual, through vitiated vascular ac- 
tion, capable of communicating the disease to a second, and so of multiplying it 
indefinitely. Opposed, however, to the doctrine of contagion are the following 
considerations: 

1st. The fever is sometimes an epidemic, in its nature, laws, and effects. 

2d. The disease has in no well-attested instance spread, when removed 
from the infected districts. In the Philadelphia hospitals was this fact most 
conclusively exhibited. Here the nurses, physicians, and other attendants, 
though exposed as much as possible to any contagion which might have existed, 
were exempt from the disease. As an experiment, the black vomit, the saliva, 
and he serum of the blood, have been harmlessly inoculated into the system. 
The vapor, also from the black vomit has been breathed, and two ounces of it 
have been swallowed with impunity. 

3d. The disease has been invariably suppressed on the accession of cold 
weather, differing in this respect from contagious diseases. These from the 
free ventilation, or from the volatility and diffusion of the virus, are less preva- 
lent in warm weather. 

4th. In contagion the sphere of communication is very narrow. But in num- 
berless instances has yellow fever been taken by individuals, who had held not 
the slightest intercourse or proximity with the sick, but who had merely passed 
through the street in which the contagion was alleged to reside. 

5th. Even the line of demarcation may be drawn with tolerable precision, in- 
dicating the limits of danger, excepting when the poisoned air may be wafted 
over it by the force of winds. We have always found the spread of the fever 
to be in the direction of the wind. 

6th. Unlike contagious diseases, which originating in a single point, thence 
radiate, yellow fever simultaneously appears in remotely separated position?. 
7th. In favor of the non-contagious character of the disease an appeal might 



166 Principles a?id Practice of 

confidently be made to probably nine-tenths of the profession who have had 
opportunities of becoming conversant with it. This argument has some force, 
from the fact that the question is one much dependent for its solution upon 
the mere observation of simple phenomena. 

Bufcit has been alleged that while the fever is not generally contagious, it 
does under certain circumstances prove so — as in crowds, ill-ventilated places. 
But this assertion, however plausible, is wanting in proof. 

The cases alleged in support, are only five or six in number, which occurred 
in the country where the yellow fever seldom or never exists, and in the practice 
of men who, from the want of acquaintance with yellow fever, would be unable 
to distinguish it from malignant cases of ordinary autumnal fever. It is indeed 
to be recollected that, according to the erroneous doctrine of the time, the only 
difference in the two diseases regarded their degree of violence. 

In the immunity which is rendered by one attack of yellow fever, this disease 
has been said to resemble contagious diseases. 

But it is untrue, that in contagious diseases subsequent protection is so gen- 
erally afforded by one attack. 

No agreement exists among the advocates of the hypothesis, as to the mode 
in which this disease, acknowledged in its general character to be otherwise, be- 
comes contagious ; or, in other words, how a vitiated atmosphere operates in 
the case. 

Chisolm says, that it merely increases susceptibility to the impression of the 
virus already received into the system, and at the same time enhances 
the action, giving the fever a more aggravated and malignant shape. Pro- 
fessor Hosack maintained some "chemical combination with the virus al- 
ready secreted from the diseased body, and that thereby the contagion becomes 
more or less multiplied according to the extent and virulence of such vitiated at- 
mosphere." 

Prof. Rush supposed the contagion to originate in an exhalation from the ex- 
cretions of the patient ; but were such the case, the disease thus produced would 
be as diversified in its nature as the effluvia from these various sources. Contami- 
nated air does influence yellow fever by the induction of a typhoid state. The 
typhoid impression may be even so strong as to supplant the primary nature of 
the disease, but then the contagion would be of the typhus and not of yellow 
fever. By the researches of Webster, it has been demonstrated that, all 
climates are liable to the periodical visitation of epidemics, and that they al- 
ternate as regards their general character, two of the same nature never 
occurring in i77imediate succession. 

In our own country the yellow fever was repeatedly alternated with the spotted 
fever, a species of typhus. 

It is to be lamented, however, that in all countries in which legislation has 
attempted to put barriers to the progress of yellow fever, the most harassing 
laws are founded upon the almost exploded doctrine of contagion. 

Exciting causes. — The ordinary exciting causes of febrile affections. Sleep 
seems to have some tendency to its production. In this state, the greatest pro- 
portion of its attacks takes place. 



American Medicine and Surgery. 1 67 

Period of incubation. — The average period is from two to three days in the 
commencement of the epidemic, becoming greater towards its close, as the poi- 
son is probably more diluted. 

DIAGNOSIS 

Distinct from its exclusive prevalence in cities, and along the wharves, there 
are peculiarities in itself, so striking, and particularly the countenance of the 
sick, that it has scarcely ever been mistaken. It bears the closest resemblance, 
perhaps, to aggravated autumnal fevers. They differ in the following respects : 

r. Yellow fever originates in a miasm, which is generated only in particular 
positions, and at certain times ; while, to a greater or less extent, common bilious 
fever is incident to many climates and all seasons. 

2. The diseases differ in type and in symptoms. The difference is manifested ' 
in the pulse, tongue, respiration, discharges from the stomach, conditions of the 
secreting power of the liver, in the muscular and nervous systems, in the coun- 
tenance, and especially in the expression of the eye. 

3. The yellow fever has its seat and throne in the stomach, while the bilious, 
though of gastric origin, chiefly involves the liver. 

4. The convalescence from yellow fever Is rapid and complete ; from bilious 
fever slow and precarious. In yellow fever the susceptibility to the disease is 
destroyed or diminished by an attack ; in the bilious fever it is increased. 

5. The treatment adapted to bilious fever, totally fails in yellow fever. 

6. The mildest case of yellow fever is as easily designated as the most violent 
and malignant. 

PROGNOSIS. 

Like other malignant epidemics, the fatality is greatest at its first appearance, 
and afterwards gradually declines. 

Cases marked by forcible reaction and high fever are most favorable ; and the 
reverse are those connected with confirmed relapse, extreme epigastric or pre- 
cordial uneasiness, jactitation, delirium, or coma, or vomitings of tenacious 
albuminous matter. Still more desperate are the cases, which, with the peculiar 
physiognomy, little or no affection is evinced. Especially ominous is an eager 
desire for food, with the morbid venereal feelings to which allusion has been 
made. 

Of the worst import is that exquisite sensibility productive of tetanus or 
hydrophobia, or where the whole suffering, to an excruciating degree, is concen- 
trated in a part, (the pudenda, or testicles, more commonly,) or the tongue in 
the advanced stage rapidly clearing, or the pulse, previously bad, becoming 
with a deterioration in other respects, conspicuously better, or the occurrence of 
the black vomit. Cases thus characterized do not recover. The disease mostly 
terminating on the third or fifth day, may do so in a few hours. However 
severe the case convalescence is almost inconceivably rapid and complete. 

POST-MORTEM. 

The most prominent lesions are in the epigastric regions. On opening the 
stomach we discover, sometimes a dark fluid hereafter to be described, and the 



1 68 Principles and Practice of 

food, drinks and medicine taken, in some instances several days before, wholly 
unaltered by the digesting process. The mucuous membrane presents the evi- 
dence of phlogosis. These are also manifested by the duodenum. Nearly 
always, in Philadelphia, has the liver been healthy, though the reverse has occurred 
elsewhere. Implicated also, occasionally, are the spleen, kidneys, urinary blad- 
der, heart and lungs. The brain is but little affected, even when cerebral 
disorder is strongly marked. During the last years of its prevalence, 187c -77- 
79, instead of the inflammatory, the fever presented the congestive character. 

It has been clearly established that black vomit is only blood more or less 
altered, in proof of which it may be visibly pressed out of the vessels. When 
this fluid is discharged in great quantities, the mucous coat presents a pallid 
hue. The general appearance is that of coffee-grounds or the sediment of port 
wine, though it is sometimes sero-sanguinous, and sometimes exactly like the 
menstrual fluid. The black vomit, when fresh, is found to be replete with 
animalcule. Cases have been reported as destitute of all lesion. The black 
vomit is not pathognomic of yellow fever. 

PATHOLOGY. 

The nature of this fever is still almost as much disputed as other points in 
its history. Like other epidemics, influenced by various agencies, it is some- 
times inflammatory, and sometimes congestive, Sometimes the two conditions 
are blended. The disease originates in a peculiar irritation or congestion or in- 
flammation of the stomach ; which is proved as well by the symptoms as by 
dissection. ' This state involves the nervous connexions of that organ. Between 
yellow fever and the condition induced by certain poisons, both in commence- 
ment and progress, has often been observed the most striking parallel. This 
parallelism is most remarkable and may be traced by any one acquainted with 
the action of poisons. I consider the disease to consist in the action of an ex- 
tremely virulent poison upon the stomach, producing excessive disorder of that 
viscus, and involving other parts sympathetically. 

TREATMENT. 

If the patient is seen in the early stage, give a stimulating emetic. 

fy— Pul7. L belia(h< rb) .. gr.' xx. 

Pulv. Eupatorium Per " xxv. 

Capsicum " xxx. 

Infuse in half a pint of water for half an hour, allowing the patient to drink 
an infusion of capsicum or ginger. Immediately after the action of the emetic 
give the patient an alcoholic vapor bath, procure a copious perspiration, rub 
thoroughly dry, giving the patient weak salt and water to drink. Then the fol- 
lowing should be given : 

Ji— Quinine gr. ii. 

Chloride of Sodium ( " iii. 

Capsicum ... " i. 

Xanthoxylin " ii. 

Mix. — At the same time the most active counter-irritation to the spine. Hot 



American Medicine and Surgery. 169 

sand bags should be placed inside of the thighs, in the axilla, and all around the 
patient's legs, body, etc. If there is fever, give: 

P— Fluid extract Asclepias Tub ~) aa. 

•' " Cy ripedium 

" " Scutiliaria J 5 iv. 

Dose — Twenty drops in water every half hour till free diaphoresis and 
sleep is obtained. Sponge the skin frequently with a solution of sulphite of 
soda. The bowels should be moved by tablespoonful dose syrup Rhei et 
potass , to which add fifteen drops fluid extract leptandria. If the vomiting is 
incessant, try tablespoonful doses of the following every ten minutes : 

fy— Aqua dist O ss. 

Chloride of Sodium 5 i. 

Capsicum gr. xx. 

Mix. — If this is not successful, try mustard over the stomach. If the cold 
stage has supervened, camphor is very effectual, but it must be frequently re- 
peated. Nitro-muriatic acid, phosphorus, nux vomica, leptandria, should be 
tried for the abdominal pain ; if there is great nervousness, lactuca and cypri- 
pedium. Lobelia is valuable given in small but continued doses, if the nausea 
and vomiting is persistent, sinking at the stomach, prostration. If constipation 
prevails continue the neutralizing mixture, with : 

9;— Fluid extract Podophyllium gtts. v. 

" " Leptandria gtts. xv. 

Throughout all the disease the patient should be supported with beef essence ; 
the strictest attention to be paid to cleanliness, ventilation, and the most thor- 
ough hygiene. If the patient can tolerate diet, let it consist of arrow-root, 
cream, champagne iced, white of egg. • Small quantities of ice at a time held in 
the mouth, relieves the thirst. All through the case keep up active spongings, 
and if all remedies seem to fail, putrefaction supervening, depend on capsicum, 
champagne and cinchona; use them liberally, for the ofteatr given, the more 
likely to be efficacious. These three remedies prove highly serviceable in yellow 
fever. 



RELAPSING FEVER. 

The name of relapsing or recurrent fever has been bestowed upon this in- 
fectious disease, owing to the fact that at a certain period of the convalescence 
there is a relapse of all the symptoms. Epidemics of it have been frequent all 
over the wbrld, in periods of famine and destitution, and in cities where sani- 
tary laws are not observed. The symptoms commence abruptly with rigors, 
frontal headache and muscular pains, while soon febrile reaction sets in and we 
find a great heat of skin, anxiety of countenance, intolerance of light and 
sound, a white tongue and full, rapid pulse. Complaint is made of urgent thirst 
and often there is pain at the epigastrium, with vomiting of a bitter bilious fluid. 
When night comes on the symptoms become aggravated, giving rise to much 
irritability and sleeplessness. As the disorder advances there is also constipa- 



170 Principles and Practice of 

tion, scanty, high-colored urine, sometimes jaundice, and increasing prostration ; 
but just as matters seem to be assuming a threatening aspect, on about the 
third or fifth day, a profuse perspiration breaks out over the whole body, the fe- 
ver disappears and the patient is left almost free from the disease, though 
weak. The convalescent of course fancies that his troubles are over and that 
tonics and nourishment will soon restore him ; but the apyretic interval is short, 
for about the seventh day from the commencement of the disorder there is an 
abrupt relapse, a repetition of all the symptoms in a graver form, week by week 
this goes on each attack leaving the patient weaker and weaker, till on the sixth 
or seventh week he either succumbs to the poison or it terminates in recovery. 
Troublesome sequelae sometimes delay recovery, such as muscular weakness, 
oedema of the legs and feet, boils, or opthalmia. When relapsing fever recurs in 
pregnant women it has a greater tendency than many acute disorders to cause 
abortion or premature labor. It is often fatal, and frequently death takes place 
during the progress of the fever, from sudden syncope. No special lei^on can 
be detected upon making a post-mortem examination, but often the liver is dis- 
covered to be enlarged from congestion, and still more frequently the spleen is 
found considerably increased in size. The treatment is very simple. Begin 
with an emetic of lobelia, alcoholic vapor bath, and open the bowels with a mild 
cathartic ; rest in bed ; the ordinary treatment of fever observed, beef essence, 
farinaceous diet. If there is much irritability give : 

5fc— Fl'd ext. Cypripedium "] aa. 

Scutelaria > 

" " Lactuca j 3 iv. 

Dose. — Thirty drops once in two hours until relieved — as often as indicated. 
If prostration is great give stimulants. The fever should be controlled with: 
^fc— Fl'd ext. Ascelepias Tub ) aa. 



" " Serpentaria ) 5 iv. 

Aqua.. 3 ii. 

Sig. — One teaspoonful as indicated. Give as indicated to subdue febrile ex- 
citement the following, every three hours : 

#— Quinine , .'...") aa. 

Hydrastin • V 

Iron by hydrogen J gr. i . 

Mix. — The greatest possible attention should be paid to nursing, all unfavor- 
able symptoms watched and met with promptness and decision. 



TYPHUS FEVER. 

This fever arises from a specific cause ; is attended by rigors, chilliness, head- 
ache, mulberry or measly rash, frequent pulse, stupor, delirium, dry, brown 
tongue, prostration, constipated bowels, usually terminating about the twenty- 
first day. Typhus is divided into four periods, viz : the forming stage, the 
stage of invasion, the stage of excitement, and the stage of collapse. 

Symptoms. — Of the forming stage — Lassitude, giddiness and dull pain in 
the head ; a peculiar uneasy sensation in the stomach, nausea, and sometimes 



American Medicine and Surgery. , 171 

vomiting, want of appetite, thirst, pale and shrunken countenance, tremor of 
the hands, eyes dull and heavy, muscular debility. This stage lasts from three 
to seven days. 

Stage of Invasion. — Slight chills alterna:ed with flushes of heat ; tongue 
whitish or clammy; entire disgust of food, nausea and vomiting, a sense of 
weight and anxiety in the praecordium. This stage lasts from six to twenty- 
four hours. 

Stage of Excitement. — Face full and flushed, pulse full, somewhat resisting 
and accelerated ; skin dry and warm, lips parched, thirst urgent, bowels consti- 
pated, eyes red and watery, slight and transient delirium, vigilance, obtuseness 
of hearing, weight and oppression in the chest ; tenderness and fulness of the 
hypochondria, catarrhal and peripneumonic symptoms ; mind about the third 
day confused, as if stunned, great reluctance to mental and corporeal action. 
About the fourth day a red miliary eruption often makes its appearance. This 
is an essential exanthema of this disease. The voice is at first rather plaintive, 
but in the advanced periods of bad cases it becomes guttural, and " at last, truly 
sepulchral." The body exhales a peculiar odor in this disease. This stage 
lasts usually about seven days, at the end of this period it terminates in the 

Stage of Collapse. — This stage is characterized by great prostration of mus- 
cular power ; torpor of the sensorial functions ; a very frequent and feeble pulse ; 
tongue brown, dry, at last black ; incrustation of the teeth with a blackish mat- 
ter ; short and feeble respiration, difficult deglutition ; almost constant delirium, 
coma, tongue tremulous, and put out with difficulty, subsultus tendinum ; hic- 
cough, heat of the skin intense and acrid ; unequal distribution of the animal 
temperature, diarrhoea, with pain in the bowels, in the periods of severe cases ; 
urine pale, tympanitic bowels, sometimes petecchia. The foregoing sketch ap- 
plies to typhus in its regular and simple form. In this form there are mani- 
fest morning emissions and evening exacerbations. Typhus is subject to vari- 
ous important modifications. In some instances local inflammations supervene 
forming 

The Inflammatory Typhus. — The organs most liable to become the seat of 
inflammation are the lungs, the brain, the intestinal canal, the liver and peri- 
toneum. The mucous membrane of the alimentary canal and the arachnoid of 
the brain, the most commonly affected. In some instances the stage of excite- 
ment does not become developed, the stage of oppression continuing through- 
out the whole course of the disease. This variety constitutes 

The Congestive form of typhus. This modification is characterized by a 
want of reaction ; great prostration and sinking from the commencement ; 
deep pain in the head and ve:tigo; face pale and dingy; respiration anxious 
and oppressed ; pulse small and variable ; skin cool, damp and relaxed ; coun- 
tenance bewildered or vacant; eyes dull, watery and red, or glairy and staring 
without redness ; bowels at first constipated, towards the conclusion, copious, 
involuntary stools ; tongue pale and tremulous, becoming at last brown and 
rough petecchia? ; passive haemorrhages ; coma ; sometimes from the beginning 
complete torpor and insensibility. The depressed and prostrated state of the 
system depends on internal venous congestion. But the symptoms at first 



172 • Principles and Practice of 

may be very insidious — merely lassitude and debility, sense of fatigue, im- 
paired memory, rigors slight, alternated with flushes of heat, pain in the head, 
back, limbs, loss of appetite and general stupor ; and these symptoms may pre- 
vail for a week or two, and the patient not quite sick enough to go to bed till he 
becomes slightly delirious. The tongue is very significant. As the disease pro- 
gresses the eyes become suffused ; the measly eruption prominent ; the counte- 
nance dingy, there is ringing in the ears and deafness ; incoherent talking, de- 
lirium, tremor, coma, etc. The symptoms, however, are much modified, ac- 
cording to the severity of the attack, the parts most specially affected. 

Causes. — The poison of typus is a specific, agent, developed where a number 
of persons are crowded together in close, filthy, ill-ventilated apartments. This 
specific animal poison rarely makes its impression unless the health is somewhat 
impaired. When all the organs are in a normal condition and operate in a 
healthy manner, an equilibrium is maintained which enables the system to resist 
the action of noxious agents. It is a disease unknown among savage tribes; it 
requires the unnatural and artificial habits of civilization to depress the vital 
forces for the reception of the poison. Typhus originates in any thing which 
tends to impair the essential or vital properties of the blood ; over-crowding, de- 
fective ventilation, insufficient nourishment. Its accession is marked by no 
very special symptom, but such as occur in acute diseases generally, unless it be 
the stupor, sensorial disturbance ; and about the fifth or eighth day the mulberry 
eruption not fading on pressure, but persistent ; the duration of the fever being 
from fourteen to twenty-one days. 

Typhus is pre-eminently a disease of the blood — the animal poison acting 
primarily on the blood ; thence on all the organs of the body. This poison is 
supposed to act as a ferment — one portion of the poison being endowed with 
the property of communicating it to another ; and then a series of decomposi- 
tion takes place within the blood corpuscles, which give rise to other fermentF. 
In other words, we have the mysterious chemical process known as catalysis, 
the operation of which is one substance acting upon another, developing in it 
latent powers and properties not hitherto seen. 

^Prognosis. — Free and spontaneous vomiting, in the beginning, particulaily 
when it relieves the giddiness, generally indicates a mild course of the disease. 
Hemorrhage from the nose about the seventh day is favorable. Very manifest 
remissions in the morning, are always a good sign. Moderate diarrhoea, du- 
ring the first days is favorable ; but when it occurs in the latter periods of the 
disease, it is a very bad sign. Great thirst, in the stage of collapse is favorable, 
so also is a moist tongue, in this stage. The absence of important or violent lo- 
cal inflammations, always a good sign. 

Diminution of frequency of the pulse, and of the acrid heat of the skin, is fa- 
vorable. Among the symptoms which are particularly unfavorable are: great 
change of the expression of the countenance in the beginning of the disease ; en- 
tire absence of thirst ; constant and violent delirium ; early petecchia, strong 
peri-pneumonic symptoms ; swelling of the parotids. The most dangerous 
signs, in the last stage are : blindness, involuntary flow of tears ; difficult deglu- 
tition ; palsy of the tongue; constant low murmuring; and entire abandonment 



American Medicine and Surgery. 173 

of himself ; a very frequent and smaller pulse ; pain in the region of the bladder; 
tenderness and tumefaction of the abdomen ; floccitato; continued motion of 
the hands and fingers ; diarrhoea; insensibility to the effects of stimulants, hic- 
cough ; apthas ; suppression of the urine, etc. 

Treatment.— Whenever typhus fever prevails there should be the most thor- 
ough hygiene, cleanliness, and ventilation, and powerful disinfectants used. 

The patient, if possible, should be placed in a well ventilated apartment, and 
a vessel of chloride of lime or some other disinfectant, kept constantly present 
and, if the weather permits, a fire in the room. If a patient is seen in the in- 
cipient stage give an emetic of lobelia, eupatorium, and capsicum, and repeat if 
necessary ; then thoroughly cleanse out the bowels with 

I* Podophyllin o- r i. 

Leptandrin gr.ii. • 

Bi-tartrate of Potass 5i. 

Dissolve in water and give at a dose ; then a vapor bath, keeping the bowels 
open with small doses of the neutralizing mixture, and the body should be 
sponged every three hours with tepid water medicated with nitro-muriatic acid. 
One pound nitro-muriatic acid to seven gallons of water, cold to the head ; 
water or beef essence impregnated with phosphoric acid as a drink. This acid 
has a most salutary effect upon the blood, as well as in the whole secreting sys- 
tem, a powerful renewer of life, a preventive to the rapid change that is going 
on under a terrible, destructive animal poison. ' • 

For the purpose of restoring the assimilative functions of the stomach, pro- 
ducing an intermission, making an effort to mitigate or abort the disease, we are 
favorable to the following, combined in various proportions : 

9;— Sulph Quinine 1 

Scutillarin .'.'.'.".!.! aa - 

Cypripedin f 

Prussiate Ferri j § r - xxx - 

Mix. — Make fifteen powders and give one every three hours. If there is 
great irritability, large doses of lactuca. The only nourishment is brandy and 
milk ; the former to prevent change or waste, the latter as food ; nursing should 
be continued steadily, both day and night. The recumbent position should be 
carefully observed ; if there is retention of urine the catheter should be used. 
Our best remedies during the stage of convalescence are, nitro-muriatic acid, 
hydrastin, gold thread, wine bitters, phosphorus, glycerine. 



TYPHOID FEVER. 

An endemic fever, infectious and contagious, of a strong, nervous type. 

Symptoms. — Typhoid fever varies in its modes of attack. The invasion is 
sometimes sudden and distinctly marked, occurring unexpectedly in the midst 
of health ; more frequently it is gradual and insidious, some deficiency of bodily 
and mental vigor, general uneasiness and discomfort, pain and feebleness in the 
limbs, dizziness, disturbed sleep, loss of appetite, foul tongue, and even nausea 
being felt for several days— sometimes a week, or even longer. Accession 



JJ4 Principles and Practice of 

often begins with intense frontal headache on waking in the morning ; though 
sometimes there is only^a sense of heaviness with vertigo ; a shivering fit of va- 
riable intensity soon follows, and is succeeded by increased heat of skin and 
frequency of pulse. A rapid and striking change in the physiognomy now 
takes place ; the expression is besotted, the face is flushed, the hearing is dull, 
with ringing in the ears ; the intelligence is weakened, and there is sensible mus- 
cular debility shown by the staggering walk. Diarrhoea is often an early and 
prominent symptom, setting in with the fever, though obstinate constipation 
may exist. 

Epistaxis frequently takes place in the early days of the disease ; it is usually 
slight and recurrent, though sometimes excessive ; when trifling and the patient 
is in bed, the blood escapes into the pharynx and is rejected mixed with mucous 
as dark round sputa. The disorder being now established, headache, if previ- 
ously absent, is felt. There is considerable disturbance of the sanguiferous 
system, the pulse being large, resisting, and over ioo. After two or three days 
it becomes softer and quicker ; in young persons, females and adult males of 
irritable constitutions, it often reaches or exceeds 120. The skin is dry and 
pungently hot, thirst is urgent and constant; the secretions of the mouth are 
thick and glutinous ; the tongue, which was furred, becomes, dry and clammy, or 
coated at the base and in the center, the edges being red. As the mouth dries, 
the whole mucous membrane acquires a uniform red color, the lips crack, and 
the teeth look brilliant from the dried layer of mucous which covers them. 
Anorexia is complete, and there is often nausea with vomiting of bitter and 
greenish matters. The diarrhoea is persistent, four or five thin, yellow evacua- 
tions taking place daily, attended with pains in the bowels, the abdomen is dis- 
tended and tympanitic, there is pain on pressure around the umbilicus, and 
pain and gurgling on pressure in the right iliac region. 

The spleen is generally enlarged, shown by increased dullness on percussion 
in the left hypochondrium ; it sometimes extends below the margin of the ribs. 
Slight cough generally exists from the outset, with the expectoration of viscid, 
greenish sputa, and quickened respiration. 

From the fifth to the ninth day the peculiar typhoid eruption appears. It con- 
sists in minute, rose-red spots, disappearing on pressure, from half a line to two 
lines in diameter, of a circular form and slightly raised above the level of the 
skin ; generally found on the abdomen and lower part of the chest, they are 
sometimes met with on the back, arms and thighs. The eruption does not 
make its appearance on all the points at once ; nor is its duration always the 
same ; in some cases it disappears entirely after two or three days ; at other 
times it persists during twelve or fifteen ; in the latter case it consists of several 
successive crops, as each rose spot is visible for three or four days only, and 
sometimes less. Before fading, it generally becomes darker in hue. The 
symptoms of the nervous centers now increase ; the muscular debility is ex- 
cessive ; the patient lies motionless on his back, or there is a tendency to slide 
down in the bed ; he seems perfectly indifferent to his situation ; his features 
are immovable, he desires to be let alone; questions, when heard and undei- 
stood, are slowly and reluctantly answered, and often with evident ill-humor— 



American Medicine and Surgery. 175 

the replies being brief and dry ; the perception of surrounding objects is vague ; 
women make slight or no efforts to resist exposure of their persons ; the eyes 
are injected and brilliant, but have an expression of unusual stupidity ; sleep is 
unrefreshing, and disturbed by vivid, startling dreams. The headache dimin- 
ishes, or ceases entirely about this period. The face is swollen and the cheeks 
of a lurid red. The pulse is soft, rapid, and often irregular ; and diminution in 
the intensity and duration of the first sound of the heart, with sometimes its 
total extinction, is met with in many cases. There is complete deafness ; with 
irregular and involuntary movements of the tendons of the arms and the hands ; 
convulsive twitchings of the nose and upper lip and great wakefulness. De- 
lirium generally occurs during the second week and is first manifested at nighf, 
the usual period of febrile exacerbation ; it is peculiar, usually tranquil and 
rambling, though sometimes it is violent, with a disposition to talk loudly, leave 
the bed and roam about. Sometimes the patient, at this period, falls into a 
drowsy state — the coma somolentum of authors — from which he cannot be 
roused except for a few moments. There is now an aggravation of all the gen- 
eral symptoms ; the tongue becomes dryer, browner, fissured and trembling ; 
sometimes it is of a bright red color and smooth, as if covered with a coat of 
varnish. The mouth and teeth are covered with dark sordes ; there is great 
difficulty or even inability to swallow or protrude the tongue ; this may arise 
from paralysis of the muscles of deglutition, but often the half dried muco- 
sites collect around the base of the tongue and render the attempt painful or 
impossible. The nostrils become obstructed by dried mucous or blood, and the 
breathing has a peculiar whistling sound. The pulse is quick and irregular ; 
diarrhoea is abundant, and the stools are often passed involuntarily ; there is 
retention of urine; and hemorrhages may occur from the nose, bowels, and 
uterus. Concurrently with these symptoms, petecchia are sometimes observed. 
A peculiar- odor is exhaled from the body, by some said to resemble that from 
mice. The heat of the body is acrid. Sloughs are apt to form, for in no acute 
disease is ulceration of the integuments more common than in this. They occur 
in about one-fifth of the cases, and ar.e generally found on those parts of the 
body exposed to pressure, as the sacrum, occiput, heels, trochanters, etc. To- 
wards the close of the second week, or beginning of the third, a decided change 
or turn takes place. If the attack is to terminate in recovery, the symptoms 
abate, the expression of the face is more natural, the pulse slower and steadier » 
the patient takes notice of what is passing around him ; the skin becomes moist, 
soft and of natural temperature, and the tongue cleans rapidly. Some critical 
evacuation, as sweating, not unfrequently precedes this amelioration. If, how- 
ever, the disorder is to prove mortal, there is a decided increase in severity of 
the symptoms, or new ones supervene. 

State of the Blood. — The condition of the blood in typhoid fever has been 
studied with a good deal of care within a few years. Andral, Bouillord, For- 
get, Simon, and a number of others, have published the result of these investiga- 
tions. " The blood in typhoid fever," the late Dr. Franz Simon remarks, " ex- 
hibits the characters of hyperinosis perhaps more distinctly than in any other af- 
fection ; hut the statements regarding its qualitative and quantitative composi- 



176 Principles and Practice of 

tion are still very contradictory, arising probably in part from its varying in the 
different stages ; thus in the period of excitement it may incline towards a state 
of hyperinosis; in the state of depression, the fibrin gradually decreases, and 
lastly, in the stage of collapse, the quantity of blood corpuscles and of sol : d 
constituents decreases so remarkably, that in the case of putrid typhoid fever the 
blood (in consequence of the liquor sanguinis being too watery and deficient in 
salt?) assumes the state of anaemia. The same appears to occur in petecchial 
typhus. One source of difference is, therefore, evidently .dependent upon the 
stage of the disease at which the blood is taken ; the presence of any inflam- 
matory symptoms will also modify its constitution. 

Causes. — Intestinal fever is a contagious disease, having all the characteristics 
of contagious fevers, such as a latent period of incubation, exemption by one 
attack from all subsequent attacks. The operation of the poison belonging to 
this fever is entirely dependent on its own production in the living body — that 
being the soil in which this specific poison breeds and multiplies, and that most 
specific of all processes which constitutes the fever itself is the process by 
which the multiplication is effected. All the emanations of the sick are infec- 
tious, but what is thrown off from the intestines is most virulent. The poison 
that produces typhoid operates not only on the blood, but induces special lesions 
in the solids. The precise emanations which produce this fever are unknown • 
impure air, the gases generated from decomposing animal or vegetable substan- 
ces, may cause disease and great depression of the vital powers. Some regard 
this fever as a consequence of the proximity of wells to privies, the inhalation 
of decayed matter from which we have blood poisoning and disordered sympa- 
thetic nerve force ; the skin and glands of the small intestines suffer. Typhoid 
fever is essentially due to decaying animal matter, and is exceedingly prevalent 
in all our large cities. 

Duration. — Should be from two to three weeks, still some are prolonged to 
the fifth or eighth week. 

Diagnosis. —Typhoid is not readily distinguished from typhus fever, in fact, 
some writers include them under the same head. There is no longer a doubt as 
to their being two distinct types of fever ; one designated by the term typhus — 
which means to smoulder or burn slowly — the other designated by the term 
typhoid, which merely indicates a typhus form. I am of the opinion that en- 
teric fever wojuld be a better term for typhoid, but am unwilling to make so great 
an innovation upon old established division. I propose to give the 



American Medicine and Surgery. 



177 



DISTINCTION BETWEEN TYPHOID AND TYPHUS FEVER. 



TYPHOID FEVER. 

It possesses more of a local than an epidem- 
ic character. 

It leaves well-marked traces on the organ- 
ism alter death. 

Epistaxis is present in about one-third of 
the cases. 

Partial or more complete deafness occurs 
alike in both diseases. 

Pupils larger than natural, but the con- 
junctiva is only slightly injected. 

Tongue usually moist, but when dry it is 
small, red glazed and fissured ; when brown 
its hue is less deep, being yellowish rather 
than blackish brown. 

Intestinal hemorrhage present in one- third 
of the cases. 



Thirst and appetite. 

Tne difference between the two diseases is 
inappreciable. 
The pulse fluctuates more than in typhus. 
Sonorous rale present in nearly every case. 

Rarely is there dullness of the lung. 



Sloughing is frquent in both diseases. 

Erysipelas met with in about one-third of 
the cases. 

Cadaveric rigidity remains longer. 

Discoloration of abdomen seldom seen. 

Emaciation advances further than in ty- 
Dhus, and, in protracted cases, it becomes ex- 
treme. 

Spots on the skin disappear after death. 

Cerebral substance congested in one-sev- 
enth of the cases. 

Generally occurs in persons under forty 
years of age. 

Typhoid commences insiduously and pro- 
gresses slowly. Heat of skin moderate, or 
even absent. 

In fatal cases average duration is twenty- 
two days ; sometimes, however, extending to 
from forty to sixty. 

Eruptions different in character, though of 
a reddish hue. 

The spots disappear on pressure, only last 
for a few days, but are succeeded by a fresh 
eruption as long as the disease prevails. 



TYPHUS FEVER. 

Pre-em inently the type of a blood disease ( 

The fever-poison acting primarily on the 
blood, there is but little trace of structural 
change after death. 

Epistaxis is of very rare occurrence. 

Pupils contracted, but the conjunctiva is in- 
tensely injected 

Tongue covered with thin, white mucus in 
the early stage, but less frequently moist 
throughout the disease. 

Intestinal hemorrhage exceedingly rare, 
save from hemorrhoids. 

Constipation more persistent, and followed 
by watery diarrhoea, with griping. Inflated 
abdomen, and noise heard by pressure over 
the right iliac fossa. 



Sonorous rale only existing In one-third of 
the cases. 

Intense congestion of the lungs is common, 
with dullness of the most depressing part of ' 
the chest. 

Does not occur in one case out of twenty. 



Very frequent. 



Eruption continues visible after death. 
Abnormally congested in one-half of the 
cases. 
Usually occurs in persons over fifty. 

Heat is more marked in the early stage, and 
during the exacerbations. Early symptoms 
more violent, and their accession is more 
sudden. 

Fourteen days in fatal cases, but very few 
extending beyond the twentieth. 

Known as the mulberry rash; it comes out 
early in the disease, elevated at first, after- 
wards becoming darker 

Appears from the third to the seventh day, 
first on the trunk anteriorly ; the spots are 
irregular in outline. May be few in number 
but more frequently numerous and uniting 
to form large spots, and each patch remains 
till the termination of the disease. The 
depth of the color is regulated by the intensity 
of the fever. 



12 



i;8 



Principles and Practice of 



Miliary residis, or sudaminre, may occur in 
both diseases, in patients under forty years of 
age. 

Countenance, complexion and expression 
not indicating extreme prostration ; complex- 
ion clear, brightish pink, flush on one or both 
cheeks which is circumscribed ; anxious 
countenance 

Headache does not disappear until about 
the fourteenth or sixteenth day. 

Delirium may occur about tie eighth day, 
sometimes not until about the fourteenth ; it 
increases slowly in severity. 

Somnolence begins after the fourteenth 
day. 

Coma vigil very rarely occurs. 

Involuntary voidance of urine and fsecal 
discharges occur at a later period. 

Lack of muscular power, and about one- 
fourth of the patients keep in bed constantly 
before the seventh day ; prostration is not 
severe until the fourteenth to the twentieth. 

Hemorrhage in the cavity of the arachnoid 
never observed . 

Ulceration of the pharynx in every third 
case. 

Ulceration of the oesophagus in every fif- 
teenth case, or thereabouts. 

Mucous membrane of the stomach very 
seldom softened. 

Small intestines, mesenteric and Peyer's 
glands are invariably diseased. 

The large intestines frequently found 
ulcerated. 

The spleen is enlarged in all cases, and fre- 
quently softened. 



Not observed in patients over forty. 



Complexion thick and muddy, flush of face 
uniform, and of a dusky red colur ; counten- 
ance less anxious. 



Disappears about the tenth or twelfth day, 
but afterwards may come on at intervals. 

Begins before the fourteenth day ; is then 
less violent ; it may be noisy but generally 
low and muttering. 

Comes on before that period. 

Present in every fifth case. 
Occur much earlier. 

Nearly all patients keep their beds entirely 
before the seventh day. Extreme prostration 
about the ninth day. A want of expression 
of the face 

Occurs in every eighth case. 

Does not occur. , 

Free from ulceration. 
Softened in a few cases. 
Invariably normal. 
Not ulcerated. 

Before the fiftieth year it is enlarged ; after 
that age it is smaller and softened, as in 
typhoid. 

The kidneys, liver, and pancreas are more 
flabby than in typhoid. 



Changes in the Blood. — In both diseases the blood becomes altered in its con- 
stituents, and the fibrin diminishes in proportion to the duration and intensity of 
the disease. The blood corpuscles increase, but the red color and fibrinous 
consistence of the normal vital fluid are greatly diminished. 

MORBID ANATOMY. 

The constant lesions found in persons dying of typhoid fever are in the folli- 
cles of the small intestines and mesenteric glands. On examining the exterior 
of the small intestines of those who have died from the fifth to the eighth day, 
reddish, blue or black opaque discolorations sometimes covered with false mem- 
branes and corresponding in situation to the diseased follicles, are visible along 
the curvature. On pressing these spots between the fingers they are found to 
be hard and unequal. On opening the intestines by an incision along the mes- 
entery, the agminate follicles (glands of Peyer) will be discovered in one or 
both the following morbid conditions : 

i. Soft Patches — Slight prominence ; the mucous membrane a little softened, 



American Medicine and Surgery. 179 

and the surface smooth or mammillated. On cutting into the elevated patch, 
the mucous and subcellular tissues are moist, injected and thickened. In some 
instances the gland has a reticulated appearance, the tissue resembling the pa- 
renchyma of the cherry or plum, the mucous membrane being softened and 
readily detached. 

2. Hard Patches — More elevated than the preceding variety ; elastic to 
the touch ; on division the sub-mucous tissue appears to be transformed into a 
homogenious matter of a pale yellowish hue, firm and friable. The surface is 
plane and shining. This species occurs in about one-third of all the cases ; 
usually in those which terminate at an early period ; and is supposed to be con- 
nected with the more severe and rapid forms of the disorder. 

3. Ulcerated Patches — are observed after the ninth or twelfth day ; there 
are two varieties ; in one the ulceration begins in the mucous membrane, and 
extends to the gland, which it gradually destroys ; in the other the yellow mat- 
ter of the gland first softens, the mucous membrane being consecutively in- 
volved, and easily detached in shreds. 

Sometimes the peritoneum is perforated by the extension of the ulceration, 
or from the formation and subsequent separation of an eschar ; these perfora- 
tions are about a line or two in diameter, are single or multiple, are found in the 
lower part of the small intestines, and when the altered patches are but few. 
The number of diseased patches varies from one to thirty or forty ; they bear 
no proportion, either in number or degree of alteration to the symptoms during 
life. 

The isolated follicles (glands of Brunner), frequently present the same alter- 
ations as the agminate ; when affected they appear as conical, rounded eleva- 
tions, about the size of a hempseed, and resemble large pustules. This condi- 
tion is found only in the lower half of the ilium. 

The mucous membrane between the follicles is in about four-fifths of the 
cases more or less softened and injected. In those dying after the 20th day, a 
simple gray or slaty discoloration is seen only. 

The mesenteric glands are as constantly affected as the intestinal follicles. 
Their condition varies with the epoch of the disorder. From the fifth to the 
thirteenth day they are merely enlarged, softened and friable, and in hue from a 
delicate rose to a deep red. 

Treatment. — We must, in order to be successful, appreciate the true condi- 
tion. We must bear in mind that the typhoid fever poison is not the disease. 
It is the partial death which this agent has caused that is the disease. It is that 
which chieflydemands our attention. We must ask ourselves, Is vitality de- 
pressed, and where can aid be rendered ? If the patient is seen early we per- 
ceive that the organs of digestion are arrested and the stomach should be emp- 
tied with : 

Jfc— Pul. lobelia herb gr xx. 

Eupatorium per " xxv. 

Capsicum •' xxx. 

Infuse in a half pint of hot water and give one-fourth every fifteen minutes. 
Its effect on the brain is salutary. The skin is hot and dry and calls for artifi- 



l8o Frinciples and Practice of 

cial moisture ; there is deficient perspiration and evaporation. Then sponging 
the entire body should be resorted to several times daily, followed by brisk fric- 
tion with the dry hand. At this early stage we are often able to stimulate the 
depressed vital forces that the patient recovers without running through the te- 
dious process of a fever, hence friction with warm salt water over the nape of 
the neck, shoulders, and abdomen is excellent. The stimulus is reflected to the 
brain, and it may be repeated once or twice daily. Then give 

Jfc— Fid. Ext. Serpentaria \ aa 

" " Asclepias Tub L 

" " Xanthoxylum ) 54. 

Dose. — 1 5 drops in warm water once in three hours, until heat, respiration 
and pulse are lessened. In connection with this, one of the following powders 
should be administered every two hours : 



fy— Sulph Quinine. 



I 



Prussiate Ferri ) grs xij. 

Capsicum " iii. 

Mix. — Make six powders. 

Nourishment should be liberal. Beef tea and milk, perfect rest in recum- 
bent posture, and, to appease thirst, a tea of boneset. On no condition 
must there be a cathartic given. With the above treatment we can frequently 
prevent or abort an atttack of typhoid fever. The above treatment however, 
is only proper the first three or fcui days of the fever. 

If unable to repair the shattered vital forces, and so break up the fever, we 
must prepare for the general management of the fever for three or four weeks. 
Every thing should be done to restore lost energy. The best ventilated apart- 
ment should be selected for the patient, and antiseptics exposed therein. Bed 
should be placed in the middle of the room, head due north, in harmony with 
magnetic law. The bedclothing should be either silk or flannel. The nurse 
should be young and vigorous. The practice of engaging elderly ladies to 
nurse the sick, or permitting them to sleep with them, or near them, is 
highly deleterious. The reflex emanations from one to the other are prejudicial. 
We have a good illustration of this in children being sickly and puny who sleep 
with the aged. 

There is a decided law of assimilation. We become like each other in all 
things. The serpentaria, asclepias and xanthoxylin should be administered in 
suitable doses to control the circulation and keep moisture on the skin. A few 
grains of quinine should be daily given to stimulate the vital forces. The pa- 
tient should be kept rigidly in the recumbent posture and on no account per- 
mitted to get up. Heat and moisture, that is a warm poultice of hops, flaxseed 
or elm, with pulverized lobelia lightly sprinkled over it, should be kept over the 
abdomen day and night, and warm bricks to the feet. The patient should be 
bathed daily, which should be followed by brisk friction with the dry hand, and 
then afterward bathed with olive oil. Milk or beef tea should be administered 
regularly day and night every few hours. No fruit or solid food allowed. No 
cathartic should be administered— enemas only. Sleep must be procured 

I 



American Medicine and Surgery. 181 

for which purpose try the following : A hop pillow below the head. If that does 
not answer the purpose give : 

fy— Fid. Ext. Lactuca ) aa 

" " Humulus ) 5 iv. 

Dose. — Thirty to forty drops every hour. Begin early in the evening and give 
thirty drops every hour until sleep is procured. Repeat every night if it op- 
erates favorably. If it does not, try the following : 

9;— A qua Camphor 3 iv 

Fid . Ext. Cypripidium , 5 iv 

" " Scutellaria 5 iv. 

Mix. — One teaspoonful every hour until sleep is procured. Sleep is indis- 
pensable in health and disease. Independent of its restorative action, the sec- 
ondary process of digestion is carried on under its influence, and especially is it 
necessary in such fevers as typhoid. In order to stimulate the mucous mem- 
brane of the stomach and bowels, and thereby promote assimilation, we have 
found the following excellent : 

I?fc-Fld. Ext. MyicaCer ) aa 



" " Populus Trem. )3i 

" " Capsicum.. 3 ss 

Boiling water Oi. 

When cool give in tablespoonful doses. Frequently this acts as a local alter- 
ative to the ulcerated bowels and mucous membrane, keep the tongue clean. 
If thirst is' great, gum arabic water, marsh mallow tea and fifteen drops of di- 
lute phosphoric acid once in four hours all the way through. Give in a wine- 
glass of sweetened water. This seems to fortify the system against the action 
of the poison and' may be given in all cases of typhoid fever with efficacious 
results. If there is great foetor, a tablespoonful of brewer's yeast added to the 
milk may with great advantage be given twice a day, or if this is not procurable, 
a decoction of wild indigo weed. If there is diarrhoea, it must be at once 
checked by : 

9;— Fid. Ext. Myrica Cer ) aa 

" " Geranium Mac ) 5 i 

Mix. — And give twenty drops after every action of the bowels. If there is 
tenesmus, give : 

9-Fld. Ext. Humulus ) aa 



" " Nymphcea odor ) 5 ii 

" -' Myrica Cer , 

Mix.— Give in half pint of starch-water by the rectum. 

If there is prostration with tremor, low muttering delirium, irregular pulse, 
brandy should be administered in quantities sufficient. The remtdy should be 
commenced at the proper time, and liberally given, so that the nervous system 
should not feel the destructive change going on. 

As a general thing there are few remedies that act upon the ulcerated glands 
of the bowels, and in the ordinary run of cases where perfect rest and good 
nursing is attended to, little is demanded. Besides the myrica, turpentine has a 



1 82 Principles and Practice of 

good effect in doses of from ten to fifteen drops three times a day in mucilage, 
on or about the tenth or twelfth day, for two days. 

Nitro-muriatic acid dilute is also invaluable — a few drops in water. 

Attention to the state of the bladder is most important, suppression of urine. 
All complications should be watched and vigorously met. Guard carefully 
against pneumonia, which is the common sequel, for nothing is more discour- 
aging than to have the patient upset by any thing whatever. 

During convalescence greater care will be required than after other forms of 
continued fever, since any irritation applied to a cicatrizing ulcer in the ilium 
will possibly affect it unfavorably and re- excite that morbid action, which may 
end in perforation. 

Tonics are to be carefully given, none being more suitable in the beginning of 
convalescence than some preparation of bark and myrica. The return to a 
generous diet must be very gradual ; no solid food allowed until the tongue has 
become clean and moist, the pulse scft, and till all feverish excitement has van- 
ished, until which time, also, the patient should neither be allowed to leave his 
bed, nor even to sit up much in it. , 



SURGICAL, OR TRAUMATIC FEVER 

Is the name given to the general febrile state which is apt to follow injuries or 
operations. 

The nature of such fever varies with the degree of the injury, the particular 
part affected, and the constitution and habits of the patient. If he is robust and 
vigorous the inflammatory symptoms will be of the sthenic kind. There 
will be a full and quick pulse, a hot skin, a high temperature, a flushed face, 
suffused and blood-shot eyes, and great thirst. 

If delirium (traumatic delirium) comes on, as it often does, especially in those 
who have been accustomed to take large quantities of alcohol, it is furious in its 
character. The patient is ungovernable, talks loudly and is under the influence 
of delusions. Sometimes he is inclined to be merry, but more often he is an- 
gry. He tosses himself in bed, is always wanting to get up, a,nd does not seem 
to feel any pain from the injury, however severe it may be. 

Treatment. — This must be active emetics, cold to the head, active purgatives, 
diaphoretics, treating the disease upon general principles, according to cause, 
extent of injury, etc. If on the other hand, if the patient is of broken health or 
of a feeble constitution, the symptoms will be of the asthenic or irritative type— 
the pulse quick and small, the tongue brown, the skin pale and clammy, the 
features pinched, and the expression anxious. If delirium ensues, it is of a low 
muttering kind, or else it is busy, meddling and suspicious, like delirium tre- 
mens. The bowels should be relieved and then give 

J£fc— Fid. Ext. Laetuca ~\ aa. 

" " Humulus )5iv. 

Dose.-. — 30 drops once in two hours until sleep is induced. It will generally 
be found advisable to give it in whatever the patient has been accustomed to 



American Medicine and Surgery. 183 

drink. At the same time he should have plenty of plain nutritious food. In 
all cases of traumatic delirium the patient will have to be restrained, so as to 
prevent his getting out of bed. If possible, this should be done by persuasion, 
management, skilful nursing, and gentle force. If more than this is required 
it will be necessary to put on a strait- waistcoat. Such a waistcoat is made of 
strong cotton cloth or of ticking and extends from the root of the neck to the waist. 
The sleeves are long, so as to extend some little distance over the hands, and 
closed at the extremeties. A cord is generally tied around them below the 
hand, and carried down to the foot of the bed so that the patient is obliged to 
keep his arms by his sides ; or else they are crossed over his chest, and secured in 
that position. The waistcoat is usually furnished with shoulder straps through 
which a belt may be passed in order to restrain the movements of the patient's 
body. We have described extreme cases as types of two forms of traumatic 
fever, but in practice they are often found more or less blended. 



HECTIC FEVER. 

A form of remittent fever of long and indefinite duration consisting of an 
exacerbation once or sometimes twice a day, attended with extreme attenuation 
of the body, and depending either on suppuration or upon important organic 
derangements of the body. 

Symptoms. — The symptoms of hectic fever, when it is fully formed, are very 
characteristic. Like other fevers it is obscure in the beginning and can scarcely 
be distinguished from the febrile state at the commencement of continued fever, 
or that which attends some chronic internal inflammations, chronic visceral de- 
rangements of structure, and gastro- intestinal irritation. The pulse is generally 
frequent, varying between 90 and 120 — always irritable, so that slight sources 
of excitement increase its frequency — and usually small, jarring, yet compressi- 
ble. Irregular exacerbations c ccur, preceded frequently by chilliness, attended 
with heat of skin, some flushing of the features, and a burning sensation in the 
palms and feet, but not always followed by perspiration. 

Although the exacerbations occur irregularly upon the whole, they are ob- 
served to be most frequent after meals, especially breakfast, and to recur very 
regularly in the forepart of the night, at which time the paroxysm is generally 
greater than at any other period. The digestive functions are at this stage not 
unfrequently, yet by no means invariably disturbed, the tongue being coated 
the stomach weak and the bowels subject to constipation. There is always 
much debility ; and the emaciation is commonly great in proportion to the 
amount of fever, and other functional disturbances, although some remarkable 
exceptions are observed to this rule, even in that most unequivocal of all forms 
of hectic which attends pulmonary consumption. The irregular febrile par- 
oxysms gradually pass into a continual state of excitement of the pulse with a 
regular exacerbation of fever occurring at least once, and often twice in the 
twenty-four hours, usually at the same period of the day. The principal ex- 
acerbation commonly begins towards evening, reaches its height about midnight 



184 Principles and Practice of 

or a little later, and goes off early in the morning. The paroxysm of exacerba- 
tion of hectic is essentially a paroxysm of remittent fever. The cold stage is 
often wanting, especially when the disease is fully formed. The hot stage is al- 
most invariably followed by considerable perspiration, unless means be taken to 
prevent it. The interval is generally one of remission merely, the pulse con- 
tinuing frequent. 

Diagnosis. — The diagnosis of hectic fever is an object of much importance 
in practice, both directly on account of the disease itself and its treatment, and 
also indirectly for the sake of the inferences which may be drawn from its 
presence and absence in various diseases. In some circumstances, for example 
the presence of hectic may determine the question of the existence ot certain 
organic disorders ; and in others, as in chronic pleurisy, it may point out the 
pathological termination of the disease and the nature of the fluid effused. For- 
tunately, it is for the most part easily distinguished from all other fevers by the 
characters which have just been given above. With one form only of fever is 
it apt at times to be confounded, namely, certain varieties of irritative fever, es- 
pecially those which attend chronic internal inflammations. In all states of debility 
the skin is frequently observed to be bathed in perspiration as often as the pa- 
tient awakes. But this recurrence is easily distinguished from the sweating of 
hectic by its happening at all times of the day indifferently, and by the sweating 
of hectic taking place whether the patient is asleep or awake, and generally in- 
deed, before the approach of sleep in the early part of the morning. 

Causes. — Hectic may arise from a great variety of gastro intestinal irritations 
such as errors of diet, foreign bodies in the alimentary canal, especially irritating 
poisons, diarrhsea and the sequelas of intermittents ; also irritations of the pul- 
monary mucous membrane from foreign bodies or chronic catarrh, gonorrheal 
or leucorrheal irritation of the mucous membrane of the genital organs — ex- 
cessive hemorrhagic discharges, protracted lactation, excessive sweating, and 
extensive chronic diseases of the skin, mental irritation or exhaustion from ex- 
cessive study, and violent passions, general bodily fatigue, excessive atmospher- 
ic heat or cold, and finally from organic diseases of internal organs, and suppu- 
ration either of internal viscera, or in other more external parts of the body. 
The most remarkable and characteristic cases of hectic occur along with inter- 
nal suppuration, such as ulceration of the lungs, consequent upon tubercular de- 
position, purulent effusion into the chest, the result of chronic inflammation of 
the pleura, suppurating tumors in the pelvis or abdomen, lumbar abcess and 
the like. There is likewise no question that hectic fever may be occasioned by 
serious organic diseases without purulent matter being formed. Cancerous af- 
fections for example, sometimes engender all the phenomena of hectic, before 
they reach the stage of suppuration ; and the same is observed to occur in re- 
gard to some chronic inflammations, such as chronic pleurisy and chronic pneu- 
monia. Hence in chronic inflammations, the advent of hectic fever is not so 
unequivocal a sign of suppuration having taken place as many practitioners im- 
agine. 

Treatment. — The treatment of hectic fever is necessarily in part subordinate 
to that of the fundamental disease on which it depends. But there are likewise 



American Medicine and Surgery. 185 

certain measures which may be resorted to for mitigating more directly the se- 
verity of the febrile action. In the generality of cases a somewhat generous diet 
including nutritive articles of food, and even the moderate use of stimulating 
liquids is found to support the strength without increasing the febrile action. In 
every circumstance, however, the diet should be easily digestible and not too 
abundant, otherwise the stomach is enfeebled, and the heat and restlessness of 
the exacerbations increased. Give syrup hypophosphites : 

Jfr— Hypophosphite Soda 1 

Calcis ', aa 

Potass f — 

.Ferri I ° lv - 

Simple Syrup Oi. 

Mix. — Shake well and give a teaspoonful before each meal. In connection 
with this we may give : 

p;— Quinine gr xx. 

Capsicum , gr. xx. 

20 powders — 1 powder three times a day. 

The patient ought to be confined in cold weather to apartments maintained 
at a uniform and moderate temperature ; and at night when the sweating stage 
of the exacerbation approaches, the bedclothes should t be diminished as far as is 
consistent with his feelings. In mild weather, however, and in a suitable cli- 
mate, great advantage is found in persevering with gentle out-of-doors exercise 
as long as the strength will permit. One of the most important objects of treat- 
ment in hectic is the diminution of colliquative sweating. In addition to the 
means already pointed out for this purpose, it is found that advantage is some- 
times derived from the tepid salt water sponging of the head, face, chest and 
arms, in the early part of the night before the sweating stage sets in. Of all in- 
ternal remedies for the same give the following : 

Jfr— Fid. Ext. Populus Trem ~| aa 

" " Geranium Mac J iS 

Mix. — 1 teaspoonful to 1 pint of warm water — drink freely during the day. 
The general line of treatment other than the above will depend upon the cause 
and must be governed accordingly. 



DENGUE. 



Definition. — An acute febrile affection, of short duration, due to an unknown 
external, specific cause and prevailing in extensive epidemics which are chiefly 
confined to warm climates ; it consists of two distinct, brief febrile paroxysms, 
each attended by a different group of symptoms, and separated by an intermis- 
sion lasting from a few hours to several days. The first is characterized by 
continuous high fever, distressing pains in the joints and muscles, interfering 
with motion, and occasionally by a cutaneous efflorescence ; it usually terminates 
suddenly with some critical discharge ; the second paroxysm is marked by a 
milder fever of remittent type, an eruption of different character which is at- 



1 86 Principles and Practice of 

tended with intense itching and followed by disquamation, by some recurrence 
of the joint-pains, and by debility ; it gradually subsides. The disease is ex- 
tremely painful, but very rarely fatal ; its morbid anatomy is therefore unknown. 

Symptoms. — The invasion of the disease is generally abrupt ; there may be in 
some cases, however, a prodromal stage of from one to three days, character- 
ized by lassitude, headache, a furred tongue, loss of appetite, muscular soreness, 
and chilliness. 

Usually, however, the patient is seized upon waking with intense headache, 
burning pain in the temples, backache, and severe pain in the joints. Some- 
times the first symptom is an acute pain in one of the joints of the hand or foot : 
this may come on while the patient is engaged at his ordinary occupation, and 
apparently in full health. The affected joints rapidly become swollen, and the 
skin of the face and neck is flushed and turgid. Painful stiffness of the muscles 
follows, the affected members are moved with great difficuly and suffering. 

The muscles of the eyes sometimes become stiff and immovable, the con- 
junctiva reddened, the eye lids swollen, so that the patient wears a staring ex- 
pression, while the eye balls feel too large for the sockets. There is intolerance 
of light and sound. At the same time symptoms of gastric disturbance occur ; 
the tongue is coated, a burning pain is felt in the epigastrium, and there is nau- 
sea, followed by bilious vomiting. The irritability of the stomach is often so 
great that scarcely any thing is retained. In most cases desire for food is whol- 
ly lost ; but not infrequently, especially in children, the appetite is retained ; 
thirst is not urgent ; the bowels are constipated. The pulse is full, hard, strong, 
and exceedingly frequent, beating from 120 to 140, and even higher in children. 
The breathing is quickened, the skin hot and dry. Confusion of thought, and 
even delirium, particularly in young children, also occur. The duration 
of the first febrile paroxysm is variable, lasting from a few hours to several 
days. Its average duration is from two to three days. The fever generally 
abates suddenly, often with the occurrence of critical discharges, such as profuse 
sweats, epistaxis, or diarrhoea, the evacuations being dark, greenish, tawny and 
foul smelling. 

Causes — Predisposing. — There can be no doubt whatever that climate has a 
large influence in the development of dengue. It is a disease of tropical and 
sub-tropical lands. When it has occurred in colder countries, it has made its 
appearance almost exclusively in the summer or autumn, and upon the advent 
of cold weather has promptly disappeared. Its prevalence has also been re- 
stricted to sporadic cases or to circumscribed local epidemics. This disease is 
undoubtedly affected by frost. The diminution of cases after a frost last autumn, 
was as marked as the diminution of cases in our endemic climatic fever usually 
is. The disease spares neither age, sex, nor occupation. 

Infants in arms and octogenarians are equally prone to it. All classes of so- 
ciety alike suffer. The physician enjoys no immunity. He is almost invariably 
attacked. 

Exciting Cause. — The exciting cause of the disease is a specific miasm and 
while it appears to be contagious in the infected district, yet it is never carried 
to others who live beyond the line of the miasmatic origin. Its mode of inva- 



American Medicine and Surgery. 187 

sion, its rapid march, the unspariug manner in which it attacks entire families, 
cities, and even districts within a brief space of time, are opposed to the as- 
sumption that it is propagated by contagion alone. 

Diagnosis. — The diagnosis is not attended with difficulty. No other disease 
presenting analagous symptoms spreads with the same rapidity through a com- 
munity. No other disease whatever, except influenza, with which dengue can 
by no possibility be confounded, attacks entire communities, sparing neither the 
young nor the old, the poor nor the rich, and, as has more than once been 
recorded, not a single individual in a district. The natural history of dengue 
makes it unnecessary to point out the points of differential diagnosis between it 
and acute articular rheumatism, to which it presents, in the first febrile par- 
oxysm strong resemblances ; or between it and scarlet fever or measles, which 
the eruptions of the second paroxysm, are said, in certain instances, to resemble. 
Its likeness to relapsing fever is confined to its course, which is in fact that of 
a relapsing fever. 

In future outbreaks careful microscopic examinations of the blood are ur- 
gently called for, in view of this resemblance, and the discovery by Oberheimer 
of a minute organism in the blood of relapsing fever patients. 

Treatment. — The treatment is to be conducted in accordance with general 
therapeutic principles, and is for the most part symptomatic. Eliminative 
measures in accordance with the practice of the tropics have been usually 
employed in the beginning of the treatment. Emetics should be given, as : 

Jfc— Pulv. L belia (herb) gr. xxx. 

Eupatorium Per gr. xxx. 

Capsicum gr. xx. 

Infuse in half pint of boiling water, and give half gill every fifteen minutes 
until free emesis. 

Purgation is called for by the constipation which exists during the period of 
fever, and by the dark green color and highly offensive character of the evacua- 
tions which commonly take place at its critical termination. It is desirable to 
anticipate elimination by the bowels by recourse to mild, but efficient purgatives, , 
as : 

Tfr— Podophyllin gr. vi. 

Leptandrin gr. xii. 

Rhubarb gr. vi. 

Mix. — Divide into six powders and give one once in six hours, until they act 
freely. The bowels should be kept open throughout the sickness by the oc- 
casional use of syrup of rhei et potass, in suitable dose. With a view of acting 
upon the skin, give : 

Jfc— Fluid Extract Asclepias Tub ") aa. 

" Balm \—r 

" " Serpentaria J 5 iv- 

Dose. — Thirty drops once in three hours. Alcoholic vapor baths to equalize 
the circulation. To relieve the pain, give : 

9;— Fid. Ext. Cypripedium ) aa. 

" " Lactuca : ) 5 iv. 

Dose. — Thirty to forty drops at night — repeat if necessary. 



1 88 Principles mid Practice of 

For local application to relieve pain in joints, use : 

fy— Tr. Belladonna Fol "1 aa. 

" Aconite Fol r— — 

' Hyosciamus ) 2 i. 

" Arnica . . ) aa. 



Chloroform ) S ss. 

Apply over the affected joint and muscle, twice a day. The itching, which is 
so distressing a symptom in the second paroxysm, and during the desquamation 
which supervenes, may be in part relieved by the application of lotions of sul- 
phite of soda. 



ERUPTIVE FEVERS. 



The eruptive fevers are continued fevers, with the addition of an eruption. 
The diseases of this class are small-pox, measles and scarlatina. They br:ar a 
strong resemblance to some diseases of the skin, but as they are due to the 
presence of miasm taken into the system and afterwards affecting special parts, 
the mode of classifying them under fevers is the proper course to pursue. 

These fevers, then, have a common character, a certain period of incubation, 
a certain time elapsing between the poison being inhaled and the establishment 
of the fever, a time, also, during which the patient's health is apparently unaf- 
fected. The fever, when it makes its appearance, is of an inflammatory or 
continued type, runs a defined prescribed course. 

They are also attended by an eruption which runs through a regular series of 
changes, and they affect the individual not more than once in a lifetime. They 
arise in all cases from a specific contagion, their progress cannot be stayed or 
cut short, but their severity can, in all cases, be mitigated or abridged by ap- 
propriate medicines, or modified by hygiene, by the most thorough nursing and 
attention to certain rules. 



CHICKEN-POX. 



Varicella of trifling infectious form, almost peculiar to infants and children. 
This form runs through all its phases in from six to eight days. Sometimes, if 
the vital forces are low. it runs the usual course. It consists of an eruption of 
pimples, which on the second day become converted into transparent vesicles, 
surrounded by slight redness. 

Rash commences on the shoulders and back, and afterwards affects the scalp, 
sparingly seen on the face. About the fourth day the vesicles form small 
scabs which rapidly dessicate. Very little, if any, constitutional disturbance, 
very little fever. It never occurs but once in the same person ; has a short in- 
cubation, four days ; not liable to small-pox afterwards ; not, however, positively 
exempt. The only treatment required is small doses of the neutralizing mixture 



American Medicine and Surgery. 189 

serpentaria and asclepias, sponging with alkaline wash, and, during convales- 
cence, elixir cinchona et ferri, gold thread, tonic bitters, iron, etc. 



SMALL-POX. 



Variola, a continued infectuous fever, attended with an eruption. Due. to the 
absorption of a specific poison. There are several grades or types, varying in 
intensity and virulence according to the amount of the poison absorbed, and 
the vital tonicity of the patient. This poison gains access to the body by the 
salivary glands of the mouth. 

This disease has properly rive stages : incubation, twelve days ; primary fe- 
ver, three days ; eruption, appearing on the third day of fever ; scabbing on the 
ninth or tenth day ; falling off on the fourteenth, and secondary fever. 

This disease is divided into two varieties, the confluent and distinct. The 
distinctive character of the former is : pustules confluent, depressed, irregularly 
circumscribed, the intervening spaces being pale, and the fever continuing after 
the eruption is completed, The distinctive character of the latter is : pustules 
distinct, elevated, distended, circular ; the intervening spaces being red, and the 
fever ceasing when the eruption is completed. 

DESCRIPTION OF THE DISTINCT KIND. 

At first aching pain in the back and lower extremities, lassitude and loss of 
appetite, slight chills, nausea and vomiting, with some soreness in the fauces, 
and finally fever. Towards the end of the third day of the fever, the eruption 
makes its appearance, first on the face and neck, and successively on the infe- 
rior parts. Just before the eruption appears, adults generally perspire freely, 
and sometimes become comatose. Children frequently suffer convulsions at 
this period ; the fever ceases the fifth day. At first the eruption consists of small 
red spots, rising by degrees into pimples, then becoming vesicular on the top 
with a small pit in the centre, and finally about the eighth day becoming pustu- 
lar, and of a spheroidal shape. About this period, 'the fare and eyelids swell, 
the tumefaction subsiding again about the eleventh day. The pustules are at 
their full and perfect state on the twelfth day ; from this date they begin to 
shrink and dry, the matter forming crusts of a brown color ; in a few days more 
these crusts fall off, leaving the skin underneath of a brownish red color. The 
pustules are surrounded by an aureola of a damask-rose color. When the pus- 
tules are numerous, some degree of fever occurs on the tenth or eleventh day. 
In these cases, there is usually some soreness of the throat, hoarseness, and a 
copious discharge of thin fluid from the mouth. 

THE CONFLUENT VARIETY. 

In this variety, all the above mentioned symptoms of the early stage are se* 
verer ; pain in the loins, in the forming stage very severe ; the severer this pain, 
the more certainly will the disease assume the confluent character. Seldom any 



190 Principles mid Practice of 

profuse perspiration just before the appearance of the eruption, as in the dis- 
tinct kind ; instead of this diarrhea often occurs at this period. Great soreness 
and redness of the fauces, and generally a copious flow of saliva. The pustules 
appear earlier than in the distinct kind— seldom later than the beginning of the 
third day — very rarely as late as the fourth or fifth day. The pustules are not 
surrounded by an inflamed margin. Where they are separated, the intervening 
skin remaining pale and flaccid. The face is always much swollen — the swell- 
ing coming on earlier than in the distinct variety, and declining about the tenth 
day. The matter in the pustules is never thick and yellow, as in the distinct 
variety, but of a whitish brown and sometimes dark color. About the eleventh 
day the pustules break and pour out a fluid which hardens into brown or black 
crusts. When these fall off, the skin underneath desquamates, producing small 
and permanent depressions, or pits, in the skin. The fever does not cease, but 
remits on the appearance of the eruption, increasing again about the sixth day 
and continuing throughout the whole course of the disease. 

CAUSES. 

The large majority of cases of small-pox originate in contagion. I am 
firmly convinced it is pre-eminently a blood disease which has an affinity for 
filthy persons, filthy abodes, crowded tenements, and those whose habits of life 
are such as to lower the vital powers and invite contagion. In the South the 
negro race is subject to contagion of small-pox in the proportion of twenty to 
one, that is, we have twenty cases among the negro race to one of the white. 
The negro race is exempt in proportion as his habits and mode of living ap- 
proach that of the white. Those who are cleanly in person and abode are much 
less subject to infection than those of opposite condition. The same holds good 
with the Caucasian. It will be found that the class of people who pay most at- 
tention to cleanliness and hygienic laws are seldom attacked with small-pox — 
can come in contact with it with almost perfect impunity when the secretions 
and system are in a healthy, active condition. There is an acid condition of 
the whole system affecting every secretion, hence the value of alkaline agents 
both as prophylactic and remedial agents. 

Thus we are led to the conclusion that while small-pox is a contagious dis- 
ease, it may be developed in crowded tenements where great numbers congre- 
gate in the same room, sleep in the same apartment and breathe the exhalations 
over and over again. This will, no doubt, produce the peculiar blood poison 
and give rise to the small-pox, which may thus be conveyed from one to anoth- 
er, Small-pox often appears in military camps, emigrant ships, where this con- 
dition exists, and 1 believe there can be no doubt of its originating in this way. 

diagnosis : 
Before the appearance of the eruption, the diagnosis of small- pox is always 
Hable to uncertainty, even with every attention to the character of the prevail- 
ing epidemic for the precursory symptoms are common to other diseases. The 
grounds on which we attempt, at this early period, to determine the nature of 
the approaching disorder, are : 1st, The suddenness of the attack; 2d, Th? 



American Medicine and Surgery. 191 

absence of previous ailment ; 3d, The exposure to variolous contagion, and 
4th, The having previously undergone one or more of the exanthemata. 

The diseases with which, after the occurrence of febrile eruption, small-pox 
may be confounded, are measles, febrile lichen, varicella, and secondary syph- 
ilis. 

1. The papulse of true small-pox are firmer than those of measles. They 
feel granular, like hard bodies, under the finger, In measles, too, there are ac- 
companying coughs and watering of the eyes. Furthermore, forty-eight hours 
elapse in small-pox from rigor to eruption ; seventy-two hours in measles. 

2. Febrile lichen is the disease from which small-pox, at the onset of eruption 
is with most difficulty distinguished. The aspect of eruption is in both cases 
nearly alike. The surest and safest grounds of diagnosis are based on the in- 
terval which has elapsed from rigor to eruption, and the seat and extent of 
eruption. In febrile lichen twenty-four hours elapse from sickening to erup- 
tion. In small-pox, as we have said, forty-eight. Small-pox almost always ap- 
pears first on the face ; the eruption of lichen is equally developed, from the 
first, on the trunk and head. 

3. The diagnosis of chicken-pox has been already pointed out. 

4. There is a form of secondary syphilis, in which an eruption appears on 
the face and trunk very similar to distinct small-pox. This eruption passes 
through the several grades of papula, vesicle and pustule. It is preceded -by a 
febrile attack of variable duration. The circumstance has in many instances 
given rise to the notion of small-pox occuring twice. A case of this kind fell 
under our own observation very recently. The diagnosis is to be effected by 
accurate inquiry into the prior history of the case. The pustular syphilitic 
eruption runs a tedious course, exceeding ten days ; and the pustules are devel- 
oped, not simultaneously as in small-pox, but in successive crops. 

Prognosis — The danger in small-pox is dependent on a variety of circum- 
stances, but chiefly on the following : 

1. On the quantity of the eruption. 

2. On the condition of the mucous membrane. 

3. On the state of the fluids. 

4. On the state of the nervous system. 

5. On the age of the patient. 

6. On his habit of body. 

7. On the crcumstances in which he is placed, and the treatment adopted. 

Hoarseness at an early period of the disease is always unfavorable. A natu- 
ral tone of voice, again, is a good omen, even though the eruption be full and 
confluent, with a disposition to cellular inflammation. The condition of the 
fluids is a circumstance by which the physician will in a great degree be guided 
in his prognosis. Every thing which indicates malignancy and putrescency is 
highly unfavorable. 

Children who grind their teeth seldom do well. Age is a point of great mo- 
ment in estimating the comparative degree of danger in confluent and semi-con- 
fluent cases ; the extremes of life are those on which small-pox always falls the 
heaviest. Persons above forty years of age seldom recover even from semi-con- 



192 Principles and Practice of 

fluent small-pox; infants are in danger even from a moderate eruption; in both 
the process of cicatrization is attended with great exhaustion of nervous power, 
the result of which is that some internal organ necessary to life (the larynx, 
brain, or lungs) takes on acute and rapidly destructive inflammation. The hab- 
it of body is, of course, also to be taken into account. Small-pox is always ag- 
gravated by its concurrence with plethora. The probability of recovery must 
depend upon the circumstances under which the patient is placed ; on the pos- 
sibility of applying remedial measures effectively ; on the treatment which has 
been pursued in the early stages, and ether contingencies which scarcely admit 
of enumeration. 

In certain seasons and states of the air, small-pox is more to be dreaded than 
at other times. 

Treatment. — Variola is a blood poisoning. The morbid agents taken into 
the stomach through the saliva and absorbed, nature attempts to eliminate 
through the skin, hence the fever. Now our office is to assist nature, get up an 
active secretion — act on stomach, skin, kidneys and bowels. By this means we 
throw off the poison and leave but little to pass out through the eruption. The 
extent of the eruption depends upon the amount of poison that is to be elimina- 
ted. The, old practice of endeavoring to keep back the eruption is fallacious. 
We should endeavor to remove the cause of the eruption, and just in proportion 
as we do this we abort the dlsea^e or reduce the danger to the patient. With 
this object in view, if we have reason to suspect our patient has been exposed 
to the contagion we should, during the period of incubation, give a daily emetic 
of comp. powder of lobelia, administer diuretics and diaphoretics, sulphite of 
soda in 20 grain doses, three times a day. I am satisfied, from recent experi- 
ments, that the sulphite of soda is a real antidote to this specific poison and 
would advise its use both internally and as a bath during the period of incuba- 
tion as a prophylactic, and throughout the whole course of the disease. Then 
to sum up our line of treatment — if the disease is recognized in its early stage, it 
can be very greatly mitigated, not exactly aborted, but rendered extremely mild. 
This can be effected in the stage of incubation by daily emetics of compound 
powder of lobelia, alcoholic vapor baths, secretions regulated, and by drinking 
freely of a tea composed of equal parts of composition powder and pitcher 
plant. The former stimulates and cleanses the poisoned mucous membrane of 
the stomach ; the latter acts as a diuretic, diaphoretic, and by its alkaline prop- 
erties neutralizes the virus in the blood. The pitcher plant is said to be almost 
a specific here. If we fail, then we must bear in mind that the fever is a salu- 
tary effort of nature to eliminate the poison — an effort that must be energetically 
aided, the fever aided with asclepias and serpentaria in sweet marjoram tea. 
If constipation prevails, the neutralizing mixture is our best laxative. The 
patient should be sponged once a day with sulphite of soda. Keep up the 
vital powers by stimulants — milk punch, beef tea and milk. Watch carefully 
complications, No depleting agent is admissible where we have a terribly pros- 
trating poison active. Patient should be kept quiet in bed, in a well ventilated 
room, free from carpets and curtains; bed-clothing, shirt changed daily, sponge 
promptly. A disinfectant should be employed in the room. Diet — milk punch, 



American Medicine and Surgery. 193 

arrow-root, beef tea, gruel, ripe fruit. As a drink give freely of a tea composed 
of equal parts of composition and pitcher plant. This is the best treatment. 
The more pitcher plant and composition the patient drinks, the milder the dis- 
ease becomes, the quicker he recovers. The sulphite of soda is the only known 
remedy that neutralizes the poison in the human body, and it would seem to do 
thfs by certain chemical properties. If the pustules be tardy in filling or maturing 
beef essence, milk punch, white of tgg are excellent. These can be aided" 
with either small doses of macrotin or quinine. Warm drinks must in all cases 
be given. No cold water, or ice-cream, nor ice in any form, should be applied' 
to the patient. All complications energetically met, never using debilitating 
remedies. For secondary fever — neutralizing mixture, pitcher plant, serpenta- 
ria, asclepias. If there is diarrhoea give 

9;— Fid. Ext. Geranium Mac 5 i. 

" " Myrica. Cer "ii. 

Mix. — Give thirty drops once in two hours ; nourishment, beef tea, soup, 
cream, raw eggs, alcoholic stimulants to prevent depression and arrest putres- 
cency. For sloughy or ganprenous sores, cinchona comp. et phosphorus, nitro- 
muriatic acid, hydrastia, milk, essence of beef, air cushions. To prevent pitting, 
smear the face well over with sweet oil, wear a mask and carefully exclude the 
atmospheric air, olive oil and camphor, glycerine and rose-water, equal parts, 
lime-water, puncturing the pustules, collodion, gutta percha and collodion, tinc- 
ture iodine, water dressing, oxide zinc ointment, black salve. 

Salicylic acid has been used with marked benefit ; in fact, in doses of five to 
en grains once in. three hours, it. has arrested the progress of well developed 
cases. It appears to be both prophylactic and curative in its effects, and is well 
worth a trial. 



RUBEOLA— MEASLES. 

A continued infectious fever preceded by sneezing, watering of the eyes and 
nose, complete catarrh, accompanied by a crimson rash and often attended or 
followed by inflammation of the mucous membrane of the organs of respiration. 
Measles are divided into two grades by some, but this division is uncalled 
for, being merely different degress of intensity of one affection. 

Symptoms. — After a period of incubation varying from twelve to fourteen 
days, the disease frequently commences with the symptoms of common ca- 
tarrh — namely, lassitude, slight chills, sneezing, watery and slightly red eyes, 
cough, and some degree of hoarseness. More commonly, however, the ca- 
tarrhal symptoms do not supervene, until the fever is fully developed. The 
fever is often mild, sometimes it is violent from the commencement. The skin is 
hot and dry, the tongue white and punctuated with prominent red points. About 
the fourth day of the fever the eruption appears first on the face, extending 
gradually down over the whole body. Nausea and vomiting, and sometimes 
slight delirium, and even coma in violent cases, occur shortly before the appear- 
ance of the eruption. 
13 



a 94 Principles and Practice of 

On the sixth day, the eruption begins to fade on the face, but not on 
the rest of the body ; but on the seventh day, it begins to become paler on the 
other parts, except on the backs of the hands, where it remains vivid until the 
eighth day, the eruption presents a faint yellowish appearance, and desquama- 
tion begins on the face, which, in two days more is completed over the whole 
'body. Occasionally, the eruption comes out as early as the second day, and 
sometimes, though rarely, as late as the seventh day. The eruption is not uni- 
form, but forms irregular patches, approaching the semi-circular or crescen 1 
shape. 

Commonly, the face swells considerably during the height of the eruption. 
The fever does not abate on the appearance of the eruption, but on the contrary 
increases. The catarrhal symptoms also increase in violence. Diarrhoea often 
comes on about the time the eruption declines, which when not excessive, is fa- 
vorable. The fever almost always declines with the desquamation ; in some in- 
stances, however though rarely, it continues and even becomes more alarming 
after this period. There is a very strong tendency to pectoral inflammation in 
this disease. Pneumonia and croup are most apt to occur about the time the 
eruption begins to decline. 

Ear-ache, inflammation and swelling of the eyelids ; swelling of the glands 
about the neck; herpes, porriginous pustules, tumid lip, serous discharges from 
behind the ears, and tedious suppurations, are among the sequelae of the disease. 
These consequences are generally the result of improper management — partic- 
ularly of incautions exposure to cold and damp air, and sometimes of constitu- 
tional predisposition. In children of an irritable habit of body, and disordered 
bowels, the breathing becomes sometimes much oppressed and anxious although 
no pectoral inflammation exists. The oppressed respiration here depends on 
irritation and must not be confounded with the oppressed respiration from pul- 
monic inflammation. 

Causes. — The measles, like scarlatina, now prevail in every climate, and at 
every season of the year, without our being able to trace them to any particular 
source ; so that we must infer that a poison is always in existence and ready 
to infect the predisposed. It seems to be a law of this and similar poisons 
that they vary greatly in intensity at different periods ; and thus the measles 
are frequently observed to prevail epidemically rather than sporadically, 
breaking out with great violence for a certain time and then declining. The dis- 
ease, however, is more common in open, mild winters, and during the spring 
than the summer and autumn. Though incident to every period of life, measles 
are more commonly observed in childhood, at which period the human constitu- 
tion is very susceptible of this and similar diseases. It is admitted by all ob- 
ervers, that the body of a person laboring under rubeola generates a poison, 
which either by contact or diffusion through the atmosphere, is capable of pro- 
ducing a similar disease. Measles are, therefore, both contagious and infectious. 
The contagious nature of this disease has often been proved by direct inocula- 
tion, either with blood drawn from the arm of a morbillious patient, or with se- 
rum taken from the vesicles which are occasionally intermixed with the eruption. 
The general evidence in favor of the doctrine of the infectious nature of meas'e* 



American Medicine and Surgery. 195 

is strong, and is admitted by all writers. The rapid spread of the disease in 
families, schools, and other establishments for children, and the difficulty of pro- 
tecting susceptible persons who happen to associate with the affected, are facts 
which establish the accuracy of this proposition. It is rarely that individuals are 
affected by this poison twice in the course of their lives. 

Diagnosis. — The only disease with which the measles are likely to be con- 
founded is scarlatina. For the distinguishing characters between the two see 
Scarlatina. 

Treatment.— During the whole course of the disease it is proper to attend to 
all the secretions, and, therefore, if constipation prevails it should be obviated 
by administering the neutralizing cordial, or leptandria and juglandin, or ene- 
mas. To relieve difficulty of breathing and oppression of the chest, counter- 
irritation over the chest by capsicum and vinegar, or mustard often proves val- 
uable. The entire surface of the patient must be sponged with the alkaline 
wash once a day. This gives great comfort, allays restlessness, promotes con- 
valescence. Exposure to cold must be carefully guarded against. The patient 
should be confined to bed, the apartment should be darkened and kept moder- 
ately warm. The cough is usually troublesome, and it is usually necessary to 
give mucilaginous drinks, mild diaphoreties as asclepias and lupulus, syrup of 
poppies, or simple syrup with cypripedium, and any good acidulated drink. In 
addition, if the cough proves very troublesome and is attended with great diffi- 
culty of breathing, inhaling the vapor of vinegar may prove serviceable. If the 
febrile symptoms run high give 

Tfi— Fid. Ext. Serpentaria ) a a. 

" " Eupatorium Per )5 iv. 

Mix. — Give 20 to 30 drops every two hours until free action of liver and kid- 
neys. When the cough harasses the patient at night, then the diaphoretic 
powder at night, and 

Jpfc— Fid. Ext. Prunis Vir | 

" " Humulus -! aa. 

" " Lobelia Herb [■ • 

" " Dracontium •! 5iv. 

" " Syrup I Siv. 

Mix. — Give one teaspoonful as required. If the diarrhoea prove exhausting, 
give 

9;— Fid. Ext. Geranium Mac ) aa. 

« < ; Myrica Cer ) 5i. 

Dose. — 20 drops once in two hours, with a teaspoonful of the neutralizing 
cordial, but as an open condition of the bowels proves serviceable, it should not 
be suppressed unless it is violent. 

When the eruption of measles disappears before the proper period and there 
are anxiety, delirium, or convulsions occurring, the indication evidently is to 
restore the eruption. To effect this, immediate recourse must be had to the 
warm n.ustard bath, or the vapor bath, the administration of some of the fol- 
lowing remedies, either C. tincture serpentaria, asclepias, or Pulsatilla, will be 
the best remedies, If there be debility, or any malignant tendency, nourishing 
broths, wine, milk punch, cinchona, are pre-eminently indicated. Although we 



196 Principles and Practice of 

inculcate confinement to bed, the avoidance of exposure to cold, and a 
comfortable room, still the patient should not be loaded with bed-clothes. It is 
true thorough hygiene should be enforced. 

The state of the three great cavities must be carefully watched, especially to- 
wards the decline of the eruption, and should any indications arise they should 
be met promptly on general principles. After the disappearance of the erup- 
tion it is proper to give some cooling purgative, juglandin and leptandria ; this 
is worthy of attention, as many troublesome complaints are thereby prevented. 
After the affection has entirely subsided, the patient should be warmly clad and 
not allowed to go out too early, and convalescence established upon bark, hy- 
drastis, etc. 



SCARLET FEVER. 

This is an infectious, contagious, febrile disease, characterized by a scarlet 
efflorescence of the skin and mucous membrane of fauces and tonsils, com- 
mencing about the second day of fever and declining about the fifth, and almost 
invariably accompanied by inflammation of the throat and its glands. It is essen- 
tially a disease of childhood, of a fatal type, occurring, like measles and small- 
pox, rarely but once in a lifetime. 

There are three types of this fever, three different grades of intensity of one 
affection, depending solely upon the amount of the poison inhaled and the power 
of vital resistance of the patient. They are thus classified : Scarlatina Simplex, 
where the skin is mostly affected ; Scarlatina anginosa, in which both skin and 
throat are implicated ; and Scarlatina maligna, in which all the force of the 
disease seems to be spent upon the throat and nervous system. 

SYMPTOMS. 

Scarlatina Simplex. — It commences with the usual symptoms of the initial 
stages of febrile diseases. About forty-eight hours after the commencement of 
the fever, a scarlet eruption appears, first on the face, then on the neck, trunk, 
and finally over the whole body. This eruption consists of innumerable little 
pimples running into each other. It is sometimes uniformly diffused, at others 
it appears in large blotches ; pressure with the finger causes a momentary dis- 
appearance of the redness. Soreness in the throat is generally felt soon after 
the fever is developed. The skin, during the eruptive stage, is dry, rough and 
hot; the face is flushed; tongue white with a streak of red around the edges; 
entire loss of appetite ; bowels costive. About the fourth or fifth day the fever 
and the eruption begin to decline, and in two days more disappear altogether. 
The cuticle generally desquamates after the eruption has disappeared. 

Scarlatina Anginosa. — Eruptive fever more violent than in the preced- 
ing variety. Head-ache, nausea, vomiting, praecordial oppression, and muscular 
prostration very considerable in the commencement. Stiffness and dull pain in 
the muscles of the neck. The eruption appears on the second or third day of 
the fever, at which* time the fauces exhibit a swollen and inflamed appearance 



American Medicine and Surgery. 107 

attended with painful deglutition. Pulse frequent, and more feeble than in the 
* simple variety. Intense heat of the surface and great thirst. Tongue dry and 
very florid along the edge ; great restlessness and prostration. Ulcers on the 
tonsils, particularly if the fever continues beyond the fifth day. White flakes of 
coagulable lymph adhering to the tonsils readily mistaken for ulcers. The ulcers 
generally cast off superficial sloughs as the fever declines, and then heal ; some- 
times they become foul, and discharge a thin and acrid fluid, which being swal- 
lowed, occasions exhausting diarrhcea. Deep and fatal coma sometimes occurs 
in the stage of excitement. Abdominal inflammation occasionally supervenes. 
Anasarca, a frequent consequence of Scarlatina Anginosa. 

Scarlatina Maligna commences like the former varieties. Eruption at first 
pale, assuming afterwards a dark or livid red color ; very variable in its dura- 
tion and time of appearance. Heat of the skin variable and seldom great. 
Pulse at first active, and soon becoming small and feeble. Delirium an early 
symptom. Eyes dull and heavy, and cheeks livid. Grayish ulcers soon visible 
on the tonsils— becoming finally covered with dark sloughs. Fauces clogged 
with viscid phlegm impeding respiration. A thin acrid fluid discharged from 
the nostrils in the advanced period of violent cases. Scarlatina Maligna differs 
from Scarlatina Anginosa, principally in the sudden and dangerous collapse which 
occurs in the former. The supervention of the collapse announced by diminu- 
tion of the heat of the surface, great prostration, frequent and feeble pulse, dark 
brown or black tongue ; petecchas and hemorrhage occur towards the conclu- 
sion of fatal cases — seldom before the tenth or twelfth day. 

Causes.— Epidemic scarlatina occurs more frequently in the autumn months 
after a warm summer, especially when the heat has been accompanied with con- 
tinued rains, and when the succeeding winter has been open and mild. It gen- 
erally disappears during the spring months, though in some epidemics it prevails 
in every month of the year. It occurs more frequently in the early, than in the 
advanced periods of life, and in females than in males ; so that childhood and 
the female sex appear to be more predisposed to the disease than manhood and 
the male sex. 

Children and females are much more exposed to the influence of the poison 
than men, and perhaps all children are susceptible of the influence of the poison, 
whereas, many adults having passed through the disease in childhood, may be 
said to be almost exempt from future attacks. Scarlatina appears to be a conta- 
gious as well as infectious disease. Its contagious nature has been demon- 
strated by inoculation. The infectious nature of scarlatina is a doctrine scarcely 
disputed in the present day. The rapid spread of the disease in schools, and its 
frequent communication to healthy members of families when children have re- 
turned home laboring under the disease, or during convalescence, though several 
weeks may have elapsed from the period of desquamation, are among the more 
obvious proofs of its infectious nature. It is also the opinion of those who have 
had much experience in this disorder, that clothing, bedding, or furniture of a 
room which have been used by patients during this disease, are all capable of 
infecting healthy individuals. 

The period which elapses after exposure to the influence of the poison before 



198 Principles and Practice of 

it produces its specific effects, probably varies from twenty-four hours to about 
ten days. 

Diagnosis. — The only diseases with which scarlatina may be confounded are 
measles and roseola. From measles it may be distinguished by the precursory 
symptoms ; by the time intervening between the first accession of fever and the 
appearance of the rash ; by the character of the eruption, and by the sequelae. 
Measles commences with coryza, sneezing, suffusion of the eyes, cough, slight 
dyspnoea and other catarrhal symptoms ; while in scarlatina, the first sensation 
of uneasiness is referred to the throat. 

The eruption in measles shows itself on the fourth day of the fever, but in scar- 
latina it may usually be distinguished on the second. In measles the rash is dis- 
posed in irregular portions of a crescentric form, and is slightly elevated so as 
to be sensible to the touch ; in scarlatina the eruption assumes the appearance 
of broad patches of an indeterminate shape. The rash has a different tint in 
the two diseases ; it is of a vivid red in scarlatina, but of a darker or raspberry 
hue in measles. In scarlatina, the fever does not abate upon the appearance of 
the eruption to the same extent as in measles ; the former is frequently succeed- 
ed by anasarca, inflammation of serous membranes, depositions in the joints, 
etc. The sequelae of measles are principally affections of the respiratory organs 
as bronchitis, pneumonia, croup. 

Roseola is distinguished from scarlatina by the partial and regularly defined 
rash by the absence of the angina, by the mildness of the febrile disorder, and 
by the short duration of the complaint. Deep rose-colored patches, exactly like 
roseola, sometimes appear intermixed with the rash of scarlatina. 

Treatment. — As a general rule, the successful management of all cases of 
scarlatina simplex and anginosa is very simple. If there is much nausea, a mild 
emetic, followed by warm bath, warm diaphoretic teas, as sweet marjoram. 
Patient should be kept in bed in a warm room. 65 to 75 degrees. Very soft 
clothing so as not to irritate the skin. The fever should be controlled with : 



Jjfc— Fid. Ext. Serpentaria ) a a. 

" " Asclepias 

" " Cypripedium 



) a a. 
) 5 iv. 



Mix. — Give thirty drops in warm sweetened water once in three hours. This 
stimulates the brain, and the whole venous and arterial system, prevents ex- 
osmosis, acts as a diaphoretic. To allay the irritability of the throat give : 
~fy— Tr. Sanguinaria ~) a a. 

Fid. Ext. Dracontium J 3 iv. 

Dose. — Ten drops every two hours. 
As a gargle, use : 

Bfc— Fid. Ext. Baptisia ) aa. 

" " Myrica Cer ) 5 i. 

Mix. — Add one teaspoonful to a pint of water ; wash or gargle the throat 
three or four times a day. 

Milk and lime water, beef tea as a diet. Sponging should be very delicately 
performed ; all complications carefully watched. After sponging the body it is 
often very advantageous to bathe the patient with olive oil. It serves numer- 



American Medicine and Surgery. 199 

ous purposes, promotes nutrition, soothes the inflamed surfaces, ameliorates the 
general condition. If the eruption does not strike out well, give comp. tinct. 
serpentaria ; the bowels regulated with neutralizing mixture. If there are spasms 
or convulsions, give the anti-spasmodic tincture. No dropsy will take place un- 
der this treatment. If met with from other practitioners the cure is usually- 
doubtful, still treatment should be on general principles. In the malignant form 
no treatment is of much avail, still we should persevere with diaphoretics, stim- 
ulants, anti-septics. There is a strong tendency in the medical profession to ag- 
gravate the type of the disease, still no one is entitled to pronounce it a case of 
malignant scarlet fever unless we have a fearful state of depression, decided ag- 
gravation of all symptoms, fetor of breath, dark hue on tongue, enlargement 
and suppuration of the glands of the throat, suppurative discharges from nose, 
eyes, lungs, ears, Eruption of a purplish color. Usually terminates fatally on the 
third day. 

The most common complication is anasarca, serous infiltration of the cellular 
tissue, dropsy of the three great cavities. It is true the patient may have been 
exposed to cold, and the escape of the poison through the skin checked, the 
force of elimination is thus thrown on the kidneys, producing congestion, ob- 
struction and dropsy. But this renal affection is so rarely present where the line 
of treatment indicated is used judiciously, that we are led to inquire whether the 
carbonate ammonia, brandy, iron, used by the old empirical physicians, are not 
the source of the difficulty, whether they do not irritate, arrest urea, or retain 
it in the kidneys and thus give rise to dropsy. Under the old treatment, dropsy 
comes on early, begins with chilliness, fever, headache, often vomiting. Face 
becomes puffy ; general oedema. Urine becomes scanty, dark, smoky appear- 
ance and contains albumen in large quantities. In the treatment of dropsy 
great good is derived from : 

• fy. Fid. Ext. Apocynum Can. 

Dose. — 20 drops, 3 times a day, and in administering one of the following 
powders, night and morning : 

JE£— Podophyllm Pulv Grs. x. 

Bitartrate Potass 3 iij. 

Mix — .Make ten powers. 

A tea of parsley root is excellent. 

It is good practice here to give iron. 

~fy Tr. Ferre Chlor gtts. x v. 

Aqua camphor 3 1. 

Mix.— To be given at a dose. As a prophylactic, sulphite of soda in dose of 
five to twenty grains, three times a day, is of value, and will act well after the 
disease is established. It is well worth a trial on those who have been exposed 
to the contagion of scarlatina. The diet should be generous to a fault, warm 
baths, heat over loins, flannel clothing, etc. A more rational mode of treatment, 
such as we have endeavored to lay down, is imperatively demanded by the present 
age. The old school treatment is pre-eminently disastrous to all who suffer. 

Better by far is the wet sheet, or no treatment at all, than this pernicious 
practice. Free elimination by the skin is the point to aim at. 



200 Principles and Practice of 



INFLAMMATION. 

Inflammation is the process by which local injuries are repaired, and it may 
therefore be considered as the restorative principle. By inflammation, however, 
is generally understood the state of a part, in which it is painful, hotter, redder, 
and somewhat more turgid than it naturally is ; which symptoms when present 
in any considerable degree, or when they affect very sensible parts, art attended 
with fever, or a general disturbance of the system. There are four signs that 
commonly attend it, viz : redness, pain, increased heat and swelling. 

Redness — Arises from an increase of the red particles of blood in the part. 
More blood must necessarily be contained there because the vessels which pre- 
viously conveyed the fluid are preternaturally distended, and ftie small vessels, 
which naturally contained only lymph, are now so enlarged as to be capable of 
receiving red blood. 

Pain — Increased sensibility or pain, is owing to distention of the nerves, by 
the greater quantity of blood determined to them. Parts naturally little sensi- 
tive, are quite the reverse when in a state of inflammation. Bones, though 
nearly destitute of sensation in their healthy state, are sometimes extremely 
sensitive when inflamed. 

Increased Heat — This is not yet generally allowed to exist. Though no in- 
crease of heat is manifested in internal inflammation, yet when it occurs on the 
surface of the body, an alteration sometimes of several degrees takes place. It 
is said never to exceed the heat of the blood at the heart. This in health is 
usually about ioo deg. Fahr, but sometimes in disease it rises to 160 deg. or 
even 170 deg. 

Swelling — Is owing in a measure to an increased determination of blood 
to the part, and also depends on effusion of the fibrin of the blood, which in 
coagulating, deposits serum in the surrounding cellular tissue. That the extra- 
vasation of coagulating lymph has a remarkable share in producing swelling of 
inflamed parts is unquestionable ; for it fills up all their interstices, glues their 
whole structure together, and consolidates them into one mass. Frequently, 
when its quantity is considerable it is converted into a true cellular or membran- 
ous texture, or assumes, more or less, the peculiar qualities of different organs. 
This is very evident in the bones. By means of such change, also, several loose 
parts may acquire the external properties of denser organs. Thus, the lungs 
are sometimes turned into a liver- like substance, and hence called hepatized. 
Inflammation may be either acute or chronic. 

Acute inflammation usually goes through its various stages with great rap- 
idity. The adhesive stage is marked by hardness and pain ; the suppurative, 
by irritative fever, fluctuation, and throbbing or pulsation ; ulceration usually 
succeeds in a short space of time, and the matter is discharged. 

Chronic inflammation is exceedingly slow in its progress, and is either the 
result of acute inflammation, or owing to a peculiar state of constitution, oc- 
curring in persons who have lived intemperately, or who have been depressed 



American Medicine mid Surgery. 201 

by laborious exertions and disappointments. Inflammation may also be either 
common or specific. 

Common or healthy inflammation is the kind we look to for the reparation of 
an injured part. Shortly after an injury, if inflammation of this character is 
set up, adhesive matter is thrown out upon the edges of the wound, by which 
they become perfectly united. In specific or unhealthy inflammation, the ves- 
sels have an entirely different action to what happens in the healthy, and thus 
the fluids and solids which they secrete have a decidedly opposite character. 
There are two descriptions of specific inflammation ; the first is produced by 
a peculiar condition of the constitution, as in the formation of scirrhus, scrof- 
ula, gout, etc., and the second by the application of a poison as in syphilis, etc. 
The best example of the first kind is scrofula, Persons attacked by this disease, 
have generally light hair, fair complexion, and a delicate appearance ; when in- 
flammation occurs it is slow in its progress, though easily excited ; and at last 
ulceration taking place, the discharge consists of curdy matter, or a thin serous 
fluid, not at all resembling the pus formed in healthy inflammation. 

Gonorrhoea, variola, etc., are good illustrations of the second kind of specific 
inflammation. Thus, in gonorrhoea, :he matter secreted is widely different 
from common, healthy matter, having in the first place a much larger quantity 
of mucus mixed with it, and secondly, when applied to a secreting surface, is 
capable of exciting in the part an action by which similar matter and the same 
effects can be produced. 

The matter of small-pox occasions the same result, and as far as constitu- 
tional effects are concerned it does not seem material how large or how small a 
quantity of the poison is applied, the result in each case depending upon the 
state of the constitution. 

In addition to the kind of inflammation already mentioned, there is another, 
which 1 propose to call the irritable. In this kind the nerves are more affected 
than the blood vessels, consequently the parts laboring under its influence are 
exceedingly tender to the touch. The eyes, the breasts of young women, the 
bladder and the testicles are very much disposed to this species of inflammation. 

Causes. — The true proximate cause of inflammation appears to be an increase 
of action in the vessels of the part, and an increase in the size of the vessels 
themselves. With regard to the proximate cause there has been a great dif- 
ference of opinion. Galen considered inflammation to be produced by a super- 
abundance of the sanguineous humor. Boerhaave referred the proximate cause 
to an obstruction in the small vessels, occasioned by a lentor of the blood. 
Cullen and others attributed it rather to an affection of the vessels than a change 
of the fluids. The question however is by no means satisfactorily explained. 
The exciting causes of inflammation are whatever produces an unnatural state 
of the parts, calling upon nature for its reparation, which she effects by the 
process of inflammation, as bruises, pressure, extraneous substances, etc. Me- 
chanical or chemical irritation, changes of temperature and stimulating foods 
are also exciting causes. Fever often seems to be a remote cause, the inflam- 
mation thus produced is generally considered as critical. Spontaneous inflamma- 



202 Principles and Practice of 

tion sometimes occurs when no perceptible cause can be assigned for its pro- 
duction. 

Inflammation sometimes arises from debility, as is frequently seen in the ex- 
tremities of old persons in whom the blood returns to the heart with difficulty. 
From the weakened power in elderly persons, the arteries are called upon for 
unusual exertion, and inflammation of the skin succeeds, frequently attended 
with incrustations, and sometimes with a watery secretion into the cellular tis- 
sue. Irritable persons are much more predisposed to inflammation than others, 
and wlien it occurs in them, it is of a more dangerous nature than in those who 
are not irritable. Thus in fevers when the constitution has been much weak- 
ened, the parts on which the body has been resting become inflamed, and quick- 
ly mortify. But in fractures where the system is healthy and strong, although 
the patient remain many weeks in bed, no such effect is produced. 

Terminations of Inflammation. These are quadruple. 

i. Resolution— Inflammation is said to terminate in resolution, when it de- 
clines and disappears without any structural lesion, or perceptible discharge. 
Resolution is more prompt in proportion as the organ affected possesses a higher 
degree of vitality in the serous membranes, the progress of inflammation is 
particularly rapid. 

Resolution is often accompanied by an increase of the natural secretions of 
the part that is particularly, noticed in the mucous and serous membranes ; also, 
in rheumatic inflammation. 

2. Effusion. — The effusion may be blood, lymph or serum. The termination 
by effusion of blood, most common in the mucous membranes, effusions of 
lymph and serum almost peculiar to the serous membranes — the former fluid 
forms a bond of union between the serous membranes. Such adhesions 
never occur in the mucous membranes. Serum is seldom abundantly exhaled, 
until the inflammation has assumed a chronic or sub-acute character. Drop- 
sies are the consequence of this mode of termination. Effusion of lymph into 
the substance of the solid visceras results in induration. 

3. Suppuration. — The cellular, serous and mucous tissues are the most prone 
to this termination ; the bones and tendons never suppurate. The mode of 
suppuration is different in the different structures ; in the mucous membranes 
it is a morbid secretion, the pus having a whitish, cream-like appearance. In 
the serous membranes pus is formed by a kind of exhalation, and is a thin, 
whitish or whey-like fluid, sometimes mixed with flakes. In the cellular tissue 
pus collects in circumscribed cavities, called abscesses, and is of thick and uni- 
form consistence and pale yellow color, exhibiting under the microscope minute 
globules suspended in a serous fluid. Symptoms are denoting the occurrence of 
suppuration in the inflammation of internal organs, a sensation of weight in 
the inflamed part ; change from the acute to a dull, throbbing pain ; rigors ; 
pulse losing its tension and hardness and becoming soft and full ; night sweats, 
and other symptoms of hectic. 

4. Gangrene. — Never occurs in the cartilages, nerves or bones. The cellular 
mucous, and serous tissues, are most prone to it ; more common in the perito- 
neum, than in any of the other serous membranes ; of the mucous membranes, 



American Medicine and Surgery. 203 

that lining the alimentary canal is most subject to it. The occurrence of gan- 
grene is denoted by sudden cessation of pain ; sinking pulse ; cold extremities ; 
cold sweat ; del'rium ; and cadaverous countenance. There exists in the differ- 
ent forms or inflammation, an original disposition to terminate in one mode, 
rather than another ; thus in boil and whitlow it is to suppurate ; in caibuncle to 
slough ; and in mumps to resolve ; and this disposition is so strong, that it is 
very difficult to procure any other termination. 

Varieties of Inflammation. — Inflammation occurs under five'prominent mod- 
ifications, corresponding to the five elementary tissues — viz : the cellular mem- 
brane and parenchyma of the solid viscera ; the serous membranes ; the mucous 
membranes ; the skin, or dermoid tissue ; and the fibrous membranes. 

1. Inflanvnation of the celhdar membrane, or phlegmonous inflammatioji. — 
Characterized by great swelling, throbbing pain, and by its mode of suppura- 
ting ; the pus being collected in circumscribed cavities — diffuse cellular inflam- 
mation. 

2. Inflammation of the serous membranes, or serous inflammation. — Pain 
very acute and lancinating— rapid in its course ; no tumefaction ; much sympa- 
thetic excitement of the sanguiferous system ; terminating in the exudation of 
coagulable lymph or serum, or the secretion of a whey-like pus ; adhesions are 
peculiar to this variety of inflammation ; it rarely terminates in gangrene. 

3. Inflammatioji of the mucous membrane, or mucous inflammation. — Al- 
most always produced by sudden atmospheric vicissitudes, in consequence of the 
close sympathy which subsists between these membranes and the skin. Some- 
times prevails epidemically. Pain not very severe ; unattended with swelling of 
the subjacent cellular tissue ; concomitant fever not intense ; never terminates 
without an increase of mucous secretion. No adhesions ever form. 

4. Inflammation of the skin, or erysipelatous inflammation. — Pain of the 
stinging or burning kind ; spreading ; forming vesicles ; never suppurating in 
circumscribed cavities ; dependent on a specific cause. 

5. Inflammation of the fibrous membranes, or rheumatic inflammation. — 
Pain intense and aching ; does not terminate in abscess or suppuration ; termi- 
nates by an exudation of a gelatinous matter ; or by earthy depositions ; is wan- 
dering, accompanying fever always syncchal ; rarely proves fatal except by me- 
tastatis to organs essential to life. 

Diagnosis of internal inflammation. — The existence of internal inflammation 
is ascertained by the continuance of the pain ; the appearance of the blood ; 
the state of the general vascular excitement , the effects of the external pressure ; 
the effects of position ; the character of the functional derangements ; the 
temperature of the skin ; and the nature of the exciting causes. 

Treatment.— The correct treatment of all inflammations is the administration 
of such agents internally as will get up a termination to the surface, and stimu- 
lants locally. 

Such remedies as 

P— Fid. Ext. Asclepias Tub ) aa. 



Serpentaria ) 5 iv. 

Papaver 5 i. 



204 Principles and Practice of 

Dose. — 20 to 40 drops every 3 hours. This tends to equalize the action of the 
heart and arteries by imparting tonicity to the brain ; and by blunting the im- 
pressibility of the nerve centres, equilibrium is established. , Alternate with 

^fc— Fid. Ext. Ci ichonaComp "] aa. 

" " Primus Vir > 

" " ApDcynum Can J 5 ii.» 

Dose. — 30 drops once in three hours. Locally the most powerful stimulants 
should be applied. 

Besides the foregoing treatment, strict attention should be directed to hygiene 
— rest, diet, sponging, diuretics, diaphoretics, and evacuants. 

Effusion of serum. — Serous membranes are peculiarly liable to such a mor- 
bid condition, as the periosteum, membrane of the brain, the pleura, and peri- 
toneum ; cellular tissue also obnoxious to serous effusion, and constitutes oede- 
ma or dropsy ; which, is rather a mechanical effect than a diseased condition. 
Serous effusion being a result of inflammation, our object in treatment should 
be to get rid of the depression. Put the patient under the influence of 

Yfr— Fluid extract Cimicifuga . ' "} aa. 

" " Eupatonum Pur > 

" " Uva Ursi J 5 iv. 

Dose. — 30 drops once in two hours until free diuresis. This should be followed 
by diuretics, diaphoretics and hydragogue cathartics. The following are the 
best known formula? for dispellling the effusion: 

l^fc— Podophylin grs. ii. „ 

Bitartrate Potash 5 ii. 

M/x. — Take at a dose, dissolved in water, and repeat, so that there may be 
three evacuations per day. 

J=fc— Ferri Chlo gtts. xx. 

Aqua Camphor 3 j. 

Take at a dose night and morning. Elaterin, one-twelfth of a grain once or 
twice daily, will induce free, copious watery stools. 

Should these fail give five grains of iodide potassium in a tablespoonful of 
comp. syr. stillingia three times a day. Alcoholic vapor bath every other day, 
and flannel next the skin. Effusion in the arm or leg constitutes oedema pits 
on pressure ; then rest, elevation, compression by rollers, friction, electricity, 
shampooing, simultaneously with the other treatment. 

Hemorrhage. — Another result of inflammation may occur prior to or during 
the activity of the inflammation, or the inflammation may so terminate. Vas- 
cular organs are peculiarly liable to hemorrhage — as the lungs, stomach, bow- 
els, kidneys, bladder, urethra and uterus. The asclepias, papaver, etc., should 
be persevered with, together with rest and external stimulation. If there is 
hemorrhage from the lungs large doses of lycopus vir ; if the stomach, rectum, 
kidneys, or uterus, give 

Ijfc— Fid. Ext. Geranium Mae ) aa 

" " MyricaCer ) gi 

Dose. — 40 drops in sugar and water. Then a special class of styptics should 
be resorted to, as, if from the bronchial mucous membrane, salt, iron, oil of 



American Medicine and Surgery. 205 

erigeron. If from the stomach, capsicum, salt. If from the kidneys or uterus, 
viburnum, prunifol erigeron. 

In all wounds the vessels should be tied— still there are minute capillaries 
that often bleed — then exposure of the bleeding surface to the air, elevation, 
pressure by bandages, cold, perchloride of iron, matico, spider web. 

Effusion of lymph. — A common termination of inflammation may occur in 
active inflammation ; but more apt to occur in low grades of inflammation, as 
the chronic, generally unattended by much heat, swelling, pain or redness. It 
produces thickening or adhesions, infiltration or induration. Adhesions of 
serous membranes cause infiltration or induration of glands, etc. The surgeon 
aims to procure union of all wounds by an effusion of lymph, and for this pur- 
pose and with such a view, he removes all foreign bodies, brings the edges of 
the wound in perfect apposition with metallic sutures, applies dry dressing, and 
observes that there be no symptoms of acute inflammation existing. 

Effusion of lymph for the repair of wasting structures can only occur when 
the vital forces of the patient are at par. Should the effusion of lymph cause 
adhesions between serous structures, we must resort to alteratives and absorb- 
ents, say 

]=fc— Comi). Syr. Stillingia and Yellow Dock S iv. 

Iodide Potassium , 5 j. 

Mix. Teaspoonful three times a day. • 

Apply unremittingly the irritating plaster over the adhesion. 

The same treatment is suitable where the glands are enlarged or inflated with 
lymph, only in addition apply locally discutient ointment, prepared as directed 
in American Dispensatory, which is an efficient resolvent of lymph ; here sham- 
pooing, friction or electricity is of but little avail. Where lymph remains effused 
in or upon any structure, it is apt at any time, should the vital forces of the pa- 
tient become feeble, to break down, and form an abscess. 

The formation of pus — When lymph is effused in acute or chronic inflam- 
mation, and as it breaks down the patient is seized with rigors, the pain becomes 
throbbing or beating in character, the heat diminishes, the congestion and red- 
ness disappear. 

The abscess points, softens in the center, and becomes pyramidical in shape ; 
it fluctuates and discharges itself, or art is brought to its aid. If the lymph has 
been thrown out and thickening ensues, it may break down at any time ; thus 
the rigors are the precursory symptoms in softening. Lymph thus broke down 
constitutes pus. There are numerous varieties of pus, as 1. Healthy or lauda- 
ble. 2. Serous, when containing serum. 3. Sanious, when it contains blood. 
4. Curd-like or cheesy, met with in scrofula. 5. Muco-purulent, when it con- 
tains mucus mixed with purulent matter. 6. Lardaceous, if like lard. 7. Spe- 
cific, when it contains a specific poison, as in syphilis ; and 8. Ffctrid, when 
dark and offensive. 

The accumulation of pus in any cavity, or structure of the body, constitutes 
an abscess, which may be acute or chronic ; invariably a result of inflammation. 
To aid suppuration — the breaking down of lymph — heat and moisture in the 
form of a well made poultice should be applied to the part and renewed every 



206 Principles and Practice of 

three hours. The best poultices are those made of flaxseed meal, slippery elm, 
chickweed, clover tops, wild indigo weed ; they should be light, fine, moist and 
hot. They should be continued until the pus fairly breaks down ; afterward 
the abscess opened and the poulticing continued, until the abscess has been 
thoroughly discharged, when a lotion or ointment should be applied. Simulta- 
neously with the breaking down of the lymph nature begins to throw out gran- 
ulations in the bottom of the abscess, this lymph becomes organized with blood 
vessels and nerves ; another layer is effused, the same result occurs, and such a 
process is repeated until the surface is reached, when a white milky scum makes 
its appearance which gradually overspreads it. The process of throwing out 
the lymph and its becoming organized' is termed cicatrization, and when the 
new cutis (which is the milky scum) completely covers it, then a cicatrice. It 
is frequently a point of the utmost importance to determine whether suppura- 
tion has occurred. If it happens on a surface where matter is discharged the 
physical characters of the secretion generally suffice ; but when occurring in 
deep seated parts, the discrimination of the most experienced surgeon may even 
fail in forming a correct diagnosis. 

Gangrene. — When inflammation is about to terminate in gangrene, pain sud- 
denly ceases, the redness becomes of a livid color, the congestion soft and flac- 
cid, and crepitates when pressed upon, from the fact that it contains the products 
of putrefaction; the pulse becomes small and wiry and frequent. A typhoid 
condition supervenes, features become small, contracted, and case soon termin- 
ates in death. 

The gangrenous part may be a portion of skin, mucous membrane, vessel, 
bone, or any other individual texture, or other structures may be involved 
simultaneously. The term slough is employed to denote the death of a portion 
of the soft parts, and that of exfoliation or "sequestrum " to a dead portion of 
bone. In gangrene, where yet the parts retain a certain degree of vitality, the 
object should be to restore the healthy actions, and thus avert the occurrence of 
mortification. While generally inflammation runs a regular course from a mild 
form to one more severe, reaching at length to mortification of the affected 
part, yet in not a few instances it is no easy task to trace any marks of severe 
inflammation antecedent to the occurrence of gangrene itself. This is particular- 
ly observable in such cases as ligature of a main artery, in cardial affections 
or where occurring in old age. It is, therefore, of the first importance, in the 
treatment of gangrene, to ascertain its causes. If the gangrene occurs in a 
limb, an effort should be made to stimulate a line of demarcation between the 
living and dying part. Such a line usually makes its appearance in the form of 
a red blush, which soon rises into a blister; this soon ruptures, forming a line of 
ulceration with a furrow. The line of demarcation is best secured by applying 
a warm p<ipltice of soda crackers, well covered with pulverized capsicum, 
changed as often as it becomes dry. 



American Medicine and Surgery. 207 



DISEASES OF SENSITIVE SYSTEM. 



BRAIN, SPINAL MARROW, NERVES, AND ORGANS 

OF SENSE. 



INFLAMMATION OF BRAIN. 

* This may occur from causes operating within itself, or may be, the result of 
accident ; if due to the latter cause, it seldom makes its appearance until six or 
seven days afterward. 

Brain structure being the most vital, it is the most difficult to induce a condi- 
tion of depression in it. Its symptoms and progress are extremely slow and va- 
riable, sometimes sudden, violent, terminating quickly in death ; at other times 
slow, insidious, even unsupected till manifested by coma or palsy. 

Symptoms. — There are some that are characteristic — a general feeling of lan- 
guor, lassitude, debility, perversion of nutrition, partial arrest of secretion, sleep- 
lessness, flashes of heat followed by coldness, great uneasiness, restlessness, skin * 
remarkably pale, even to whiteness ; patient extremely feverish, irritable ; men- 
tal faculties disturbed ; frontal headache, a pain that is aggravated by noise, by 
heat, motion, light ; intolerance of light ; pulse feeble but rapid ; nausea, anorexia. 
These symptoms may last a few days or even weeks, then they are followed by 
violent rigors, great heat of skin, pulse hard, rapid ; headache intolerable and 
throbbing ; light insupportable ; sound cannot be borne, face becomes flushedf 
turgid with blood, eyes suffused, lips swollen, tongue coated brown and dry, 
bowels obstinately constipated ; stomach rejects every thing ; secretion and ex- 
cretion are arrested, because the brain, that presides over all is impaired. In 
addition, violent delirium, coma, paralysis, pupils contracted, and if these are not 
speedily relieved the third stage follows ; then the pulse becomes slow, oppressed, 
strabismus, low delirium, convulsions, suppression of urine and general palsy, 
rapidly usher in death. Rigors, followed by squinting, dilated pupil, stertorous 
breathing, coma, palsy, are indications of an unfavorable termination. If the 
inflammation extends to the cortical substance and membranes of the brain, 
early derangement of the intellectual faculties, irritability, constant agitation of 
the medullary substance, chills, headache, convulsions, lassitude, etc. 

Causes. — The predisposing causes are, plethora, stimulants, excessive exer- 
cise. Exciting causes are concussions, blows, fractures, mental emotion, me- 
tastasis of rheumatism, gout, erysipelas, suppression of some discharge. If the 
membranes and surface of the brain be inflamed, there will be greater pain, a 
stronger disposition to delirium and convulsions. In inflammation of the cere- 
bral substance there is an early tendency to coma and palsy. 

The medullary substance of the brain is merely the passive servant of the 
cineritious substance, the conductor of its commands to the muscles ; the gray 



2o8 Principles and Practice of 

substance presides over the intellect, the white over movements. Inflammation 
of the brain may terminate in any of the ordinary results of inflammation, ef- 
fusion, induration, suppuration, abscess. Chronic inflammation of the brain is 
often very insidious and difficult of diagnosis, the occurrence of local palsies, 
and a peculiar change in the urine is a positive diagnostic symptom, it pos- 
sesses a low specific gravity of ioio, without albumen, a remarkable diminu- 
tion of coloring matter, of urea, chlorides, alkalies, phosphates, etc. 

Diagnosis. — The diagnosis of inflammation of particular spots of the brain 
cannot be relied upon by any precise symptoms. Pain in the head, intolerance 
of light, vomiting, drowsiness, coma, slow then rapid pulse, succeeded by jac- 
titation and convulsions before death, indicate that the inflammation is on the 
surface ; if nausea and vomiting are the earliest symptoms, the inflammation 
has its origin in the cerebral pulp ; if the attack begins with convulsions the 
inflammation has started from the arachnoid, but, as a rule, symptoms variable 
and insidious. 

Treatment. — On the first appearance of symptoms the patient should be put 
to bed in a cool, well- ventilated apartment, light, noise and heat carefully 
excluded. The head and shoulders should be well elevated. Then the head 
should be shaved, and cloths wrung out of tepid water should be kept con- 
stantly applied to the bare scalp. To the legs, a mustard roller should be ap- 
plied from the toe to the knee. Irritating plaster to nape of the neck, renewed 
if need be, from day to day. Then the next is to open the secretions. Free, 
thorough purgation is the rule, for which the following is excellent : 

1^— Podophyllin grs. ii. 

Lepiaudrin grs. Iv. 

Bitartrate of Potash g i. 

Mix. — Make one powder and give at a dose. If no movement of the bowels 

takes place, in three hours repeat. Copious enemas may also be resorted to 

until free evacuations from the bowels are procured. If vomiting is persistent, 

give tincture lobelia in small doses and apply a mustard sinapism over the 

stomach. An alcoholic vapor bath should also be given patient in bed, by 

bringing the fumes of the alcohol up underneath the bed-clothes. After this 

preliminary treatment has been rigidly attended to, we find the organism better 

fitted to receive and assimilate medicine. Powerful diaphoretics as : 

~fy -Fid. Ext. Asclepias . 3iv. 

" " Lobelia " " 

Dose. — Thirty drops every half hour; keeping up all the preliminary 

treatment, bearing in mind that from active purgation in adults we derive the 

most satisfactory results. To procure sleep is an important indication. This is 

best done by the administration of large doses of lactuca and papaver, as : 

{fc— Fid. Ext. Lactuca ) aa. 

" • " Pa aver ) Si. 

Dose. — Forty drops every hour for three hours, or until sleep is obtained. 

Repeat every afternoon during the progress of the case. 

Or give : 

ty -Fid . Ext. Cypripedium ( an 

" " Scutellaria •< — 

" " Asciepias ; ( oiv 



American Medicine and Surgery. 209 

Dose. — 30 drops once in two hours. 

The above might be combined with lobelia and given as above. In numerous 
cases of inflammation of the brain I have derived the greatest benefit from green 
lobelia ; five grains in pill form given every two hours ; prefer it in pill form on 
account of its slower absorption and being less likely to excite nausea. Lobelia 
as a relaxant and sedative, has a positive revulsive effect in all brain engorge- 
ments; it diminishes the number of respirations, controls the action of the heart, 
and abates cerebral inflammation. With these and like means we would subdue 
inflammation and if possible avoid its terminations. We would establish a cure 
upon a cautious use of phosphorus, iron cinchona quinine, counter-irritation, 
alteratives, iodide potass, with syr. stillingia,change of air, a cautious use of food 
and stimulants. * 

The diet should be extremly meagre — gruel, cracker water, etc. 

Chronic inflammation may be an independent primary disorder, or it may be a 
sequel of the acute form. Its symptoms are much diversified. In some patients 
we have symptoms very similar to acute, as headache, peevishness, sleeplessness, 
great mental excitement, either in buoyancy or depression, hesitation in speech, 
stammering, stiffness of muscles, headache, loss of appetite, constipation, irreg- 
ularity of pulse, subsequently symptoms aggravated, memory fails, senses im- 
paired, paralysis, general breaking down of all the functions of the brain. This 
form of inflammation is extremely common, caused by the excessive wear and 
tear of the brain, incidental to a high civilized state. The most marked causes 
are mental overwork, over stimulation by excess in drinking, sexual or other- 
wise, use of quinine and opium, masturbation, shocks incidental to railroad 
traveling, etc. 

In the treatment, all causes must be removed and special symptoms promptly 
met and an active course of counter-irritation and alteratives resorted to; bowels 
must be kept open, sleep procured, rest and rigid quietness observed; remedies 
administered that diminish the amount of blood in the brain, asasclepias, lobelia, 
serpentaria, change of air and location; diet should consist chiefly of vegetables, 
phosphates and fish, and the use of brain tonics carefully guarded. 

Effusion of serum or blood ofte^ takes place during the active stage of inflam- 
mation. In most cases it is recognized by the contraction of the pupil, tongue 
drawn to one side,. and paralysis of one or both sides of the body. Irritating 
plaster with syrup stillingia comp. 



WHITE.SOFTENING OF THE BRAIN. 

Cerebral anaemia, long continued, produces softening of the brain. Ramol- 
lissement, or softening of the brain, proceeds from inflammation. It resembles 
gangrene. But while softening is thus produced, it sometimes depends on 
other causes ; from exudation, which is infiltrated among the elementary nervous 
structures, from a mechanical breaking up of these structures by hemorrhagic 
extravasations, from fatty degeneration of the nerve cells, independent of exuda- 
tions; from the mere imbibition of serum, which loosens the connection between 
14 



.210 Principles and Practice of 

the nerve tubes and cells, from mechanical violence in exposing the nerve centres, 
from putrefaction. 

Symptoms. — The symptoms of the first period axe. : a fixed and violent pain 
in the head, often continuing for several months ; vertigo ; obtuseness of the 
mental faculties, the memory being weak and the ideas confused; questions are 
answered after long hesitation ; dejection ; querulousness ; indifference to sur- 
rounding occurrences ; drowsiness ; tingling and numbness in the fingers ; fre- 
quently perverted vision and occasionally total blindness; dull hearing, some- 
times very acute ; frequently nausea and bilious vomiting ; tenderness of the 
epigastrum ; constipation ; pulse variable, sometimes hard and full ; occasionally 
i there is delirium; with fever and much agitation. 

The second period is characterized by a gradual or sudden paralysis of one 
limb, sometimes of half the body ; consciousness and intellect remain ; questions 
are answered with very great difficulty, the patient generally expressing his de- 
sires by automatic movements, sometimes perfect coma; death commonly follows 
in two or three days. 

Causes. — Over-exertion, anxiety, excessive sexual indulgence, stimulants, de- 
pression, any thing that cuts off the normal supply of the blood ; disease in the 
coats of the arteries, as a deposition of earthy and fatty matter in the walls of 
the vessels ; these and other depositions impede the blood in the capillary vessels 
of the brain, preventing nourishment, which then passes into a softened state. 

Diagnosis. — Softening of the brain may supervene suddenly upon an attack 
of inflammation, or it may come on in a gradual and imperceptible manner. In- 
sensibility, dilated pupils, slight muttering, delirium, paralysis, contraction of the 
flexor muscles, constipation, uraemic odor, gradual failure of the memory, cede- 
matous state of the body, wandering, general languor, slow dragging and im- 
perfect articulation, constipation, loss of energy and ambition. 

Prognosis. — Ramollissement of the brain has been considered a fatal disease, 
and is still so when treated with depleting measures, the vital powers becoming 
exhausted. In earthy, fatty or calcareous degeneration of the coats of the blood 
vessels, it is still hopeless. But pure softening may be repaired, and a cure ef- 
fected. 

Treatment. — The grand secret of success is to improve the general well being 
of the patient, improve the blood and neurine by every possible means in our 
power. Diffusible stimulants should be given every hour, as xanthoxylum, 
tinct. capsicum et myrrh, but not pushed so strong if hemeplegia has supervened. 
Stimulate an appetite if possible, by wine, hydrastia, cinchona and other tonics. 
If there is the least disposition to sinking, stimulants are our only resource, as 
slow pulse, fainting fits, convulsions, denote ansemic debility. Let the diet be 
generous to a fault ; animal food should have the preference, adding to it iron 
and phosphorus, and other tonics. The tonic and stimulating plan of treat- 
ment always improves, frequently cures. To meet special symptoms, such 
remedies as cypripedium, Scutellaria, lactuca, cimicifuga, cinchona, hydrastia, 
lobelia, phosphorus, are of the greatest value. 

Chronic inflammation of the brain, is prone to follow an acute attack, or it 
may come on independently. The phenomena which it presents are diversified. 



American Medicine and Surgery. 21 1 

We find either great mental excitement or depression ; some absurd desire to 
be gratified, and, indeed, we have symptoms strongly allied to insanity. Slight 
hesitation in speaking, slight headache, loss of appetite, constipation, irregular- 
ity of the pulse, and as the disease advances, evidences of cerebral disorder be- 
come fully developed ; the memory fails, the senses become impaired, paralysis 
shows itself, the health gives way. Chronic meningitis may run its course in a 
few months, or may last for years. Our treatment should be such as will meet 
the symptoms very decidedly, at the same time we try by energetic hygienic 
means to support the gerferal health. 

Acute ra7nollissement, or red softening of the brain, is one of the termina- 
tions of the inflammatory process ; being often due to both the acute and chro- 
nic form of inflammation. The softening is usually partial, the parts affected 
become pulpy and ultimately of the consistence of cream. It is recognized 
by the occurrence of paralysis with spasm ; or by permanent contraction of the 
flexor muscles of one or both extremities. If it results from inflammation, the 
corpus callosum, septum lucidum, fornix, and the cerebral substance surround- 
ing the ventricles, are the parts which suffer. In these instances, the softened 
matter is infiltrated with pus, while in some cases, the purulent matter is con- 
tained in a well-defined cavity, forming abscess of the brain. Red softening is 
the result of inflammation; white softening of the cerebral substance, is the 
. opposite condition to the inflammatory, owing to a morbid process and deficient 
supply of blood. The gray matter of the convolutions at the base of the brain 
are the parts affected. Imperfect nutrition of the brain is usually due to fibrin- 
ous deposit in some vessel which impedes the supply of blood. 

Induration is frequently the result of either acute or chronic inflammation ; 
the indurated portion is of small extent, and the change is due to a deposit of 
albumen. 



CONGESTION OF THE BRAIN. 

This may arise from any cause which disturb the circulation, as the poison 
of the eruptive fevers, the irritation of teething, and a great variety of causes. 

The symptoms are, uneasiness, restlessness, irritability, disturbed sleep, heat 
of the head, and pain, which is increased by noise or movements, tension and 
prominence of the anterior fontanelle, general feverishness, vomiting, and fre- 
quently constipation. At the end of a few days, it may be that the disturbance 
will cease, and the symptoms disappear ; or, in more serious cases, we may 
have the congestion terminating in those formidable maladies, hemorrhage or 
effusion, or acute hydrocephalus. 

Treatment.— This will be varied to meet the indications and circumstances 
under which the congestion occurs. In all cases the symptoms should be con- 
trolled if possible; counter-irritation to the extremities and put the patient 
thoroughly under the influence of 



#-Fld. Ext. Asclepias Tub. 
" " Humulus Lup. 
" " Lactuca 



) aa 
J5 IV 



212 Principles and Practice of 

Dose. — 30 drops in water once in two hours. Apply over the back part of 
the head cloths saturated with the following mixture : 

fy— Aqua Dist . . O.ss. 

Chloride Sodium • Si. 

Aqua Anion Si. 

Spirits Camphor S ii 

Mix. — Change frequently. If there is not much depression, active purgation, 
clean out the intestinal tract, and if there is any suspicion of a loaded condition 
of the stomach, an emetic of the comp. powder of lobelia. Sleep should be 
induced, if possible, by 

P— Fluid Extract Papaver. 

Dose. — 30 to 40 drops and repeat until rest is obtained. Quietness, plenty of 
fresh air, cool apartments, are essential. 

Many of our profession begin the treatment with emetics : the comp. powder 
of lobelia as directed under the head of fever. 

After full emesis, the feet are immersed in warm water for ten minutes, then 
apply to the feet and body a vapor bath, (if no other way, hot steamed stones or 
bricks) using relaxants and diaphoretics internally, such as will not make direct 
impressions on the brain. Induce and maintain free perspiration upon the whole 
surface of the body ; if necessary, carry the relaxants of lobelia, etc., to vomiting; 
water or liniment to the head, and sinapisms to the spine — use cathartics and 
diuretics. In merely passive congestion, occurring during the paroxysms of ' 
hooping-cough, or from some abdominal cause, I have found the anti-spasmod- 
ic tincture highly useful ; attending to the secretions and giving 

^fc— Fluid Extract Iris Ver ") aa. 

Acid Phos. dil » J5iv. 

Dose. — 30 drops once in five hours. At the same time, the warm salt-water 
bath, keeping the head cool, and the body warm, and establishing convalescence 
upon bark, hydrastia, etc. ; nourishing food, beef tea, and soothing or allaying 
any irritability that may exist. But if the effusion terminate either in cerebral 
or meningeal apoplexy, the principles of treatment do not vary. A cooling lo- 
tion to the head, sinapisms to the extremities, lobelia, asclepia", cypripedium, 
and if prostration supervenes, stimulants. As a general rule, cerebral diseases 
occur most frequently in children of scrofulous diathesis, and the constitutional 
taint modifies the disease. The treatment of diseases of the nervous system in 
children requires the nicest discrimination and judgment. We have tender 
bodies to deal with ; the period of life modifies the action of medicines, and an 
error in prescribing is usually serious. No child should be treated with depres- 
sing remedies ; they are dangerous, and many have been sacrificed at this altar. 
There are several good land marks, diaphoretics to lessen or reduce vascular 
action ; the warm bath, a powerful agent for relieving the circulation ; mild 
purgation, to reduce the heat, remove obnoxicu^ matter, and encourage a flow 
of bile ; diuretics to promote a copious flow of urine ; and, in the advanced 
stages, iris versicolor, and the C (syr. stilingia) with iodide potassium for the 
purpose of absorption. 



American Medicine and Surgery. 213 



TUBERCULAR MENINGITIS. 

Irritation reflected from any portion of the body to the cerebro-spinal axis 
depreciates the nervous system so much that a tubercular or scrofulous diathe- 
sis is engendered. This condition may have been hereditary or acquired by 
teething, worms, bad diet, drugs, irritation of bowels, etc. When this irritation 
is carried on for a long time, we have irritation of the brain of a tubercular char- 
acter, tubercular meningitis. Most frequently attacks children under five years 
of age. 

Causes. — The predisposing are scrofulous or tubercular diathesis. 

Exciting — over feeding, opium and alcoholic stimulants, teething constipa- 
tion, interrupted secretions, sudden checking of the bowels, any irritation re- 
flected to the brain; vaccination in those predisposed will excite tubercular de- 
posit. 

Symptoms. — These are for purpose of convenience divisible into three stages. 

The first or precursory stage is ushered in by some of the following group of 
symptoms : 

Irritability and capriciousness ; headache and fullness, shown by the child fre- 
quently putting its hand to its head, or by the head hanging down, sleepiness 
and drowsiness, occasional dragging of one leg, disordered appetite, vomiting, 
constipation, elevated temperature, and disturbed sleep ; the stools pale, clayey 
and offensive ; the tongue moist, red at tip and edges, and furred in the centre ; 
the pulse quickened, seldom, however, above 120, and often irregular. The child 
does not close its eyes, grinds its teeth, and often wakes in alarm, is paler than 
natural, though there may be a transient flush, a peculiar irritative cough is a 
common and significant precursor. A pinched, drawn, haggard expression is 
very characteristic. It occurs even early in the precursory stage. Even at this 
stage, the respiration is quickened a little, is unequal and irregular, and accom- 
panied with sighing and yawning, the temperature is usually increased, though 
not so much as in other tubercular diseases. 

The recognition of this stage of the disease, the duration of which is usually 
from four to five days, is of the utmost importance ; during this time only 
has treatment any reasonable hope of success. The supervention of the secona 
stage is marked by increased moroseness of the child ; it wishes to be left alone ; 
at night there is often considerable delirium ; the pulse is slower, falls, perhaps 
to 80 or even 40, is more irregular, and even intermitting ; slight exertions, how- 
'ever, materially quicken it for a time ; there is more stupor and insensibility ; the 
child frowns almost constantly ; the face is flushed ; there is much heat of head 
and pulsation of the anterior fontanelle ; there is heard a peculiar piercing cry. 
The pupils are often unequally dilated, or there may be strabismus. The ab- 
domen is remarkably shrunken. This stage passes by insensible gradations into 
the third, which is marked by increase in the stupor, often broken into, howev- 
er, by convulsions. 

The convulsions may leave paralysis, usually the same, sometimes of the op- 
posite side. The pulse becomes small, rapid, scarcely to be numbered. There 



214 Principles and Practice of 

are clammy sweats. The pupils are widely dilated and motionless. The as- 
pect of the little sufferer is piteous to behold, with sunken face and form, eyes 
staring and sunk deep in their sockets. Convulsions constantly recur and soon 
put an end to the scene. It happens however sometimes that an improvement 
takes place for some days before death. 

This is a significant fact in the course of many chronic as well as acute dis- 
eases. Just before death a remission of perhaps the very worst symptoms 
takes place. The pain, which has been agonizing, vanishes ; the breathing, 
which had been so labored, gets easier , the purging, which had heen so uncon- 
trollable, ceases ; and the patient's friends delude themselves with false hopes. 

The physician must ever bear this in mind ; it is remarkably conspicuous in 
many diseases of children, and in none more, perhaps, than in tubercular men- 
ingitis. 

Ourselves undeceived by it, we must caution the friends from expecting per- 
manent amendment ; such second disappointment sickens the heart. 

Exceptional conditions. — The symptoms of tubercular meningitis are exceed- 
ingly variable, both in character and sequence, and while the above may be 
considered a correct sketch of the true type, almost every case will vary from it 
in some particular. The most constant and persistent symptoms are vomiting, 
constipation and retraction of the abdomen Hemiplegia and strabismus are 
not uncommon. 

Diagnosis. — From typhoid fever. In the latter disease the following points 
contrast with the ordinary course ot tubercular meningetis. It is common in 
children above five years old. 

There is often no vomiting. The bowels are relaxed, There is tenderness 
and gurgling, especially in the right iliac fossa, with a tumid abdomen, and 
abundance of flatus. The tongue is dry. There is more heat of skin and no 
irregularity of the pulse. Convulsions and paralysis are rare. From simple 
acute meningitis M. Rilliet draws the following distinctions, it must, however, 
be admitted that in most cases the two affections are almost indistinguishable ; 

i. Tubercular meningitis occurs in weak, precocious children, and in those 
subject to glandular enlargements and skin diseases ; whereas in simple menin- 
gitis the subjects are vigorous and healthy. 

2. Tubercular meningitis is always sporadic. 

3. The child previously pines away and suffers from ■ gastro-intestinal irrita- 
tion. Simple meningitis begins without prodromata. 

4. Tubercular meningitis does not commence with convulsions. 

5. In simple meningitis headache is if possble more intense, vomiting more 
urgent, constipation less obstinate, fever more violent, delirium higher. 

6. In tubercular meningitis the progress is comparatively slower. 

7. The duration is more prolonged. 

8. In simple meningitia the disease is more ataxic from the first, and the ag- 
gravations more progressive and continuous. 

Prognosis extremely unfavorable, few cases recover in which the first stage is 
past. The duration of the disease is from ten to twenty days. 

Treatment. — I. Prophylactic. When one child of a family has died of men- 



American Medicine and Surgery. 215 

ingitis the health of the father and mother should be enquired into and im- 
proved as far as may be practicable. The mother should in future not be per- 
mitted to suckle, but the infant must be reared by a good wet nurse. Besides 
this, every hygienic condition should be brought to bear upon such an infant 
His food, his clothing, his exercise, must all be carefully considered and adapted 
to his growing necessities. Sea air will always be beneficial, and baths in salt 
antl water as soon as the child is old enough. The diet must be plain, simple 
and nourishing ; stimulants are undesirable. Such a child must be allowed to 
be backward in his lessons ; all attempts at forcing his intellect must be discour- 
aged ; his health must be the first and only consideration. The parents must 
be made to understand the importance of things apparently trifling in his case, 
such as a little vomiting or constipation. Such a child should never have "home 
medicines " administered to him. The Cetraria Islandica moss is a valuable 
adjunct in diet, and the syr. hypophos ferri, or compound syr. of the phos- 
phate of iron with glycerine is the best medicines. The bowels must be most 
carefully regulated and every tendency to any disorder narrowly watched. This 
will be done by a wise mother without allowing her child to perceive that it is 
an object of undue solicitude, with quiet, undemonstrative attention, without 
any fussy, foolish interference. Great tact, great forbearance and firmness will 
be needed in the education and management of such a child. 

2. If the disease be actually established the treatment becomes an anxious 
and much disputed question. To relieve congestion apply cold to the head, an 
evaporating lotion, wet rags, ice, — all are beneficial. The hair should be cut 
close. In simple acute meningitis give diaphoreties, diureties, and apply cold to 
the head, warm salt water, or mustard water, or tr. capsicum to feet and legs. 
Keep down all excitement, have the room darkened, everything quiet, and give 
beef tea as nutriment, keeping the bowels well opened with some purgative, etc- 
In the chronic form we should rely upon hypophosphites as 

^fe— Hypophos Ferri f aa 

Calcis j 

Sola 1 * iv 

Potas 1° 1V - 

Triturate in mortar and add 

Simple Syrup .' gxvi. 

Shake well and give a teaspoonful three times a day. During the waking 
hours give 

#— Fid. Ext. Scutellaria J aa 

" " Lactuca (5iv. 

Dose. — 10 drops in a teaspoonful of glycerine once in three hours. 
The irritating plaster over the spine and nape of the neck, frequent salt-water 
bathing, perfect hygiene and a good, nutritious diet, keeping down all excite- 
ment, the head well elevated in sleep. Under this course some cases will im- 
prove rapidly and a cure be effected. 



216 Principles and Practice of 



HYDROCEPHALUS. 

This is seldom met with as a congenital disease, but is usually associated with 
disease of the cerebellum. Effusion takes place, the head attains a great size, 
the manifold sutures yield to the pressure of the fluid, the bones become thin 
and transparent, the meninges become thickened, and the effusion is uniform 
throughout the scalp generally, though may be more to one side. The amount 
of water varies, in some cases only a few ounces, in some several pints may ac- 
cumulate. 

Causes. — Predisposing cause tubercular or scrofulous diathesis, imperfect 
nutrition, the mother or nurse being of a strumous diathesis. 

Exciting Cause. — Constipation, stooping, or anything that tends to produce 
fullness of blood to the brain. 

Symptoms. — Stupor, pallor, slow pulse, picking of nose and lips, dilation or 
contraction of the pupils of the eye. If remedies take effect, the muscular 
power returns, the appetite becomes natural, emaciation gives way and general 
improvement takes place, it may be quite rapidly. 

Cases about to terminate fatally will have rapid pulsations, paralysis, coma, 
and death. 

Diagnosis. — Hydrocephalus is often the sequel of some scrofulous inflamma- 
tion, but may be congenital. There is emaciation, ravenous appetite, small 
face, large, globular cranium, head drops to one side helplessly, extreme sen- 
sitiveness to light, irritable temper, peevishness, imbecile, epileptic fits, rolling 
of eye-balls, etc. 

Treatment. — The primary causes of hydrocephalus and tubercular menin- 
gitis are all due to the scrofulous diathesis. Our treatment should be directed 
to improving, or changing that abnormal condition. As a starting point, we 
have an enfeebled condition of the nervous system to begin with, and like a 
stream of water, if the fountain is impure, we have the whole stream vitiated, 
so the blood is impure, not perfectly elaborated. Children are born with this 
hereditary taint, this sin of the parents visited upon them. Nourishing food, 
juice of meat, milk, salt water baths. Give : 

J^—Tr. Cinchona Comp 5 iv. 

Phos Acid Dil " ii. 

Pure Glycerine " x. 

Dose. — One teaspoonful morning, noon and night. We must remove the ef- 
fusion by acting on the bowels, kidneys and skin. To this end we would give 
the podophyllin powders, as : 

^fc— Podophyllin grs. v. 

Leptandrin "' x. 

Bitanrate Potass " xxx. 

Make ten powders. Give one night and morning, follow with : 

Yfc— Comp. Syr. Yellow Dock O ss. 

Iodide Potass 5 iii. 

Dose. — One teaspoonful three times a day. Apply the following to the head ; 

J^t— Muriate of Ammonia 5 i. 

Iodide Potass " ss. 

Aqua 1. 

Apply three times a day. 



American Medicine and Surgery. 2\j 



CEPHALALGIA. 

The symptoms depend upon various causes, and are connected with deficient 
morbid condition. We have organic headache from disease of the brain- 
Headache depending upon a congested condition of the cerebral veins is termed 
plethoric ; bilious headache, dependent on deranged, or imperfect action of the 
liver or stomach ; nervous headache, due to debility, or other causes. To sum 
up the condition present, and which leads to headache, we may state that fa- 
tigue, over exertion, mental or physical excitement, all these tend to produce a 
species of congestion, and weak or debilitated condition of the vessels of the 
brain, and this tends to headache. 

ORGANIC HEADACHE. 

Always due to some disease of the brain or membranes. Continued pain in 
the head, vertigo, vomiting, confusion of mind, noise in the head. The pain is 
continuous, sharp at times, at others dull and lancinating, more severe in back 
part of the head, though apparently deep in. When due to inflammation the 
pain is intense, and is increased by noise, heat and motion. 

PLETHORIC HEADACHE. 

Essentially a congestion of the brain or its membranes. Sanguine temper- 
ament, constipation, sedentary habits, too much sleep, suppression of some se- 
cretion, are all predisposing causes, while stooping occupation, etc., are exciting 
causes, and produce the peculiar throbbing pain which usually attends this form 
of headache. 

BILIOUS HEADACHE. 

Common to patients of a bilious temperament ; liver and digestive apparatus 
is always feeble and deranged, coated tongue, and offensive breath ; yellow 
tinge of the eye, appetite impaired. , 

NERVOUS HEADACHE. 

Commonly met with in patients of a nervous, sanguine temperament ; com- 
mon to conditions of impoverished blood ; often produced by the irritation of 
decayed teeth, malaria and other toxical agents ; present in all forms of exhaus- 
tion, nursing too much ; also as a result of excessive hemorrhages, hysteria, 
sexual excesses, drains upon the system from any cause. 

Treatment. — First of all correct the secretions. Act upon the liver, skin, 
kidneys, and digestive organs ; have a well regulated diet ; leave off tobacco ; 
use shower baths daily, and endeavor to remove the cause. In organic head- 
ache we would give : 

#— Fid. Ext. Buchu § ii. 

" " Podophyllum faa. 

" " Serpeutaria \ 

" " Iris Versi 1^5 i. 

Tr. Nux Vomica 5 ss. 

Dose. — Mix, and give half a teaspoonful in a wine-glass full of sweetened 
water, three times a day before meals : 



218 Principles and Practice of 

Ji— Fid. Ext. Lactuca ( aa. 

" " Humulus (Si. 

Dose. — Thirty- five to forty drops half an hour after each meal, and at bed- 
time. In headache depending on rheumatic tendency, would give the podo- 
phyllum mixture, and after meals give forty drops of cimicifuga. In headache 
the result of catarrh, give the first and follow after meals with : 

P— Fid. Ext. Papaver I aa. 

" " Asclepias ( 3 ss. 

Dose. — Twenty to forty drops in water. In bilious headache give the podo- 
phyllum, and give half hour after meals, twenty drops fid. ext. diascorea. In 
headache the result of habitual constipation, we would give : 

&— Fid. Ext Nux "Vomica : )aa. 

" " Iris Versicola joiv. 

" " Dioscorea 5i. 

Dose. — 30 drops after each meal. 

When due to chills and fever, nothing acts so well as fld. ext. cinchona comp, 
60 drops two to five hours apart, till relieved. 

The treatment of cephalalgia will depend in every case upon the cause, which 
must be attended to before any special good is accomplished. 



APOPLEXY. 



This is a state of coma from pressure within the cranium. It is characterized 
by sudden loss of sensation, thought, voluntary motion, with great disturbance 
of respiration and circulation. 

Causes, Predisposing. — Apoplexy occurs usually after the meridian of life, 
and the period most subject to it is said to be between the ages of sixty and 
seventy. The male is much more inclined to the disease than the female. It is 
often found in men of large head, florid complexion, short, thick neck, broad 
shoulders, expanded chest, tumid abdomen, low stature, and sanguine tempera- 
ment. Other predisposing causes are habits of intemperance or inactivity, ex- 
tremes of temperature, antecedent lesions of the brain or its meninges, and 
especially degenerations of the cerebral vessels in consequence of chronic and 
perhaps latent inflammation, derangements of the heart, great vessels, lungs, or 
any of the abdominal viscera, tumors of the neck and whatever else may disorder 
the circulation. But particularly productive of apoplexy is hypertrophy of the 
left ventricle of the heart. 

Exciting. — Excesses in eating and drinking or irritating ingesta, narcotics, 
worms, offensive sordes in the bowels, constipation, the suppression of an hab- 
itual discharge, the repulsion of cutaneous eruptions, exposure to the sun or 
hanging the head over a fire, long continuance in a warm bath or the shock of a 
cold bath, long exposure to a low temperature and especially the use of stimu- 
lating food or drink under such circumstances, violent exertion of the body, 
especially in a bent position, intense mental exercise, loud haranguing, etc. 



American Medicine and Surgery. 219 

SYMPTOMS. 

Premonitory. -May supervene without premonition, but is usually preceded 
by pain in the head acute or dull, vertigo, drowsiness, flushed face, strange 
noises in the ear, disorder of vision, hearing or taste, hebetude of mind, deep 
inspiration, numbness of the fingers, paralysis of the muscles of the face, a full 
irregular pulse, cramps or a sense of fulness in the stomach. 

Of the Paroxysm. — Mostly the individual falls down suddenly, deprived of 
sense and voluntary motion and apparently as if in a profound sleep, with a 
florid or livid countenance, stertorous breathing, frothing of the mouth, a dull, 
slow, interrupted circulation, hot head and cold feet, and little or no power of 
deglutition. 

Symptoms when probably the Stomach is priinarily in fault. — Preceded by 
pain in the head, severe stricture across the forehead ; a feeling of drawing in 
the muscles of the back of the neck ; vertigo; great confusion of ideas ; tremors 
of the limbs ; precordial oppression ; cramps of the stomach or bowels ; nausea 
or vomiting ; pallor of the face ; universally cold surface, and an irregular pulse. 

Afterwards may succeed convulsions or paralysis (mostly hemiplegia), and 
other marked symptoms. In either the cerebral or gastric variety, life may be 
extinguished at once. But this is seldom. Rupture of the heart, or large ves- 
sels, is sometimes taken for apoplexy. A fatal paroxyism of apoplexy seldom 
ends sooner than some hours, and usually endures several days. 

The paroxysm having lasted for some time, it is not unusual for the full florid 
countenance to be exchanged for the pallid one ; or, on the other hand, for a 
more inflammatory action to be set up, with a hard, full, accelerated pulse, warm 
skin throughout, injected eyes, dilated or contracted pupils. 

When health has been restored in other respects, the paralytic affection, where 
it exists is little improved, and the mind long remains impaired. 

Diagnosis. — Paralysis of the brain and in some of its forms, coma, and lethar- 
gus, are essentially of the same pathological condition. 

In epilepsy there is much spasmodic and convulsive movement, and especially 
of the muscles of '.he face, while in apoplexy there is a suspension of action in 
the voluntary muscles. In epilepsy the muscles are rigid, in apoplexy relaxed. 
The paroxysm of the former soon passes off. 

A fit of intoxication may be distinguished from apoplexy by an inquiry into 
the history of the case, by the odor of the liquor in the breath, and by the re- 
tention of sensibility in the upper lip to the impression of water dropped upon 
it. Distinguish from rupture of the heart, or one of the great vessels by death 
being in the latter case immediate, and the corpse being pallid. That form of 
the disease originating in the alimentary canal, may be diagnosticated by the pre- 
vious occurrence of dyspeptic symptoms, or by the patients having been engaged 
in a debauch, or having swallowed a narcotic substance. 

« The symptoms of the paroxysms differ also. The stomach being the prima- 
ry seat, there is usually much nausea or vomiting, the face pallid, skin cold, the 
pulse weak and diminutive, and the respiration comparatively little disturbed. 

The case very often resembles syncope. Cases originating in the uterus, etc., 
may be determined sometimes from their history. 



220 Principles and Practice of 

Prognosis. — The disease being uncomplicated with palsy, or, arising from 
some abdominal disorder, is the more curable. The danger, however, really de- 
pends upon the question whether there be merely vascular congestion, or extra- 
vasations from rupture of vessels, or otherwise, or effusions from pre-existing ir- 
ritation, or inflammation, or some of those derangements of structure which are 
to be noticed. 

Recoveries sometimes take place even after the extravasation of blood. 

Apoplexy, in its more vehement forms, is always a most fatal disease. Symp- 
toms of bad import are a weak, or exceedingly slow or an irregular, and es- 
pecially an intermittent pulse, very expanded or contracted pupils, convulsions, 
and particularly when of one side only. 

Post Mortem. — The arteries, and veins of the brain and its meninges turgid 
or even heavily engorged. Or only a portion of structure is involved. Most 
commonly, extravasation of blood, which may be deposited either on the sur- 
face, or, as is more frequent, in its substance. It is met with between the mem- 
branes, on the exterior, throughout the internal cerebral structure, about the base 
of the brain, and in the ventricles. It may be pure and of florid color, or 
dark, grumous, or concreted, and may vary in quantity from a few drachms to 
as many ounces. The surrounding brain may be either hardened or softened. 

Sometimes the extravasations are serous or gelatinous. Acute inflammation 
is frequently discoverable. Besides, may be sometimes observed organic 
changes, and degenerations of the brain or its envelopes, or diseases of other 
parts of the body. These are, however, rather the cause of the affection. 

Fatal cases of apoplexy may ;>ccur without any appreciable change on dis- 
section. Such instances may resulc from mere congestion ; though excessive 
doses of opium, and ardent spirits appear to extinguish life, independently of 
the disorder ihev induce in the circulatory and respiratory organs. 

Pathology. — The proximate cause of apoplexy, in most instances at least, 
is compression. This is proved by the fact that the symptoms of apoplexy dis- 
appear immediately upon the removal of the coagulum, or pressure otherwise 
exerted, and the symptoms of apoplexy to supervene directly upon the applica- 
tion of artificial pressure to the brain. 

Those cases of supposed apoplexy which have been reported as being uncon- 
nected with any lesions of the brain, or its envelopes, may have been really in- 
stances of rupture of the heart or a great vessel ; or of hardening or softening 
or other alterations of the brain, until recently overlooked ; or they may have 
been affections of the ganglionic system of nerves ; or the blood may have been 
retracted from the cerebral vessels by copious depletion, when it was, howev- 
er, too late for the brain to recover from the effects of its previous compression, 
or retracted as sometimes happens, in inflammations, at the time of death. But 
while it is contended that the lesion of the brain giving rise to apoplexy, is 
usually dependent on compression, yet it must be admitted that the same con- 
dition may exist independently of compression ; and this is what was formerly 
called nervous apoplexy. 

Writers have commonly divided apoplexy into the sanguinous and serous 



American Medicine and Surgery, 221 

varieties. But such a classification has no practical advantage. The better ar- 
rangement is into that form which is a primary affection of the brain, and that 
which is symptomatic. 

Treatment. — The treatment of apoplexy must be of an active nature. If seen 
in a paroxysm, we must adopt the most active measures. Among the best 
means, where there is coma, full, hard pulse, the vessels in the neck gorged, the 
face flushed or tinged, are the application of ligatures, at once, over the extremi- 
ties, in both axilla and groin. Then if the patient can swallow, give 

#— Fid. Ext. Asclepias Tub ) aa. 

" " Ser pentaria 

" "Lobelia ) 3 iv. 

Dose. — Thirty drops every half hour, to bring the pulse to about sixty-five ; 
friction over the back of the neck and clavicle with tr. capsicum and salt water, 
is advisable. Apply oil of capsicum and mustard to both limbs, A free use of 
enemas of flax-seed tea, in which mix ten drops each of fid. ext podophyllum and 
leptandria, and eight or ten drops of turpentine. Should this fail to move the 
bowels and the patient can wallow, give large doses of senna and salts or two 
drops of croton oil, our object being to get up an action on the bowels in the 
shortest possible time. If the patient cannot swallow, we must apply ice to the 
head and spine. 

Remove all articles of dress that can cause pressure, give plenty of fresh air. 
If we find the patient in a state of syncope, with a weak, almost imperceptible 
pulse, cold, clammy skin, a sighing respiration, we should proceed differently — 
giving a stimulating treatment, lobelia and capsicum, equal parts tincture lobelia 
and capsicum, in thirty drop doses, repeated in half an hour ; warm, stimulating 
applications to the extremities ; and if the stomach is overloaded, give a stimu- 
lating emetic of lobelia and capsicum. Bleeding must never be resorted Xo. 
Shower baths, perfect hygienic measures, etc., should be adopted to prevent a 
return. Let the bed be a straw or hair mattress ; diet plain, plenty of acids, 
wine as a drink, avoiding all fermented liquors. This, with strict avoidance of 
all excitement and exciting causes, will soon overcome the disposition to return. 
Should paralysis remain as a sequel of apoplexy, which is often the case, then 
the general line of treatment laid down under that head. 



PARALYSIS. 



Either a loss of power in the muscles, or loss of sensation, according as the 
nerves of motion or sensation are affected, or both these states may be united. 
By hemiplegia is meant palsy of one side of the body, from the head down- 
ward. By paraplegia is meant palsy of a part separated by a transverse plane 
from the hip downwards. There may be also general palsy (which, however, 
perhaps never occurs except in apoplexy), and partial palsy, as of a limb, or of 
a particular sense. Hemiplegia is more uniformly originated in the brain, and 
connected with cerebral disturbance than paraplegia. 

Pathology. — There are two opposite conditions that lead to paralysis — one is 



222 Principles and Practice of 

from pressure — too much'blood to the brain and spinal cord, producing conges- 
tion and cutting off the circulation in the nervous system. The other is where 
there is a deficient supply of blood to the cord, an anaemic condition where the 
vitality is deficient. 

In the first class of cases we have full plethoric habit ; in the latter a weak, 
pale, emaciated condition. This being the case, it is of great importance to 
distinguish between them before treating a case. 

Symptoms.. — Paralysis may occur suddenly, without premonitory symptoms, 
but usually there is a feeling of laguor, heaviness, etc., before it comes on ; in 
some cases it is very gradual. The patient finds an inability to raise the toe 
from the ground ; there may be a sense of heaviness, pricking sensation, as of 
thousands of needles sticking the skin, finally total loss of muscular power, and 
inability to bear weight on the same. This may be confined to even one limb, 
or it may affect the whole body. It is all-important to determine what condi- 
tion of the circulation we have to contend with. 

When there is too much blood to the head we have cramps, irritation and 
fulness. In treating this class we must avoid all remedies that tend to increase 
the flow of blood to the head or nerve centre. It is unnecessary for me to enter 
into full and minute description of paralysis under its many heads or names. 
The symptoms are so well marked none can fail to recognize it. 

Causes. — There are ako two great primary or predisposing causes for paralysis 
— poisoning and exhaustion. Poisoning is generally due to specific mercurial 
treatment, the use of hair dyes (lead), syphilitic poisoning, bad food, tobacco. 
Exhaustion is generally the result of abuse of sexual passions, mental labor 
carried to an excess, excitements of every kind. Paraplegia and local paralysis, 
however, more frequently proceed from some leison of the spinal marrow or of 
the nerve supplying the part. 

Diagnosis. — Palsy and apoplexy are mutually convertible diseases and may 
co-exist. The principal point is to determine the primary seat of the disease— 
whether in the brain, spinal marrow, nerve, or any particular viscus. This 
must be done by the associate symptoms. 

Prognosis. — In proportion as the individual is older, so Is the difficulty of 
cure the greater. Secondary or sympathetic palsy is more favorable than pri- 
mary, and palsy originated in the spinal marrow more curable than that of the 
brain. It has been generally conceded that palsy of the right side is more in- 
tractible than that of the left. The first indication of returning sensibility is 
frequently a sense of formication, or a feeling like the creeping or stinging of 
ants. 

Treatment. — Where there is too much blood to the cord, we should succeed 
best with Scutellaria and iodide of potass. The following will be appropriate : 

El— Comp. Syr. Frostwort Oi. 

Iodide Potass Si. 

Mix. — Dose one teaspooful before each meal ; give in say half wine glass of 
water. 

JE*— Fid Ext. Scutellaria 5 ii. 

" " Serpentaria " i. 

Dose. — 20 drops after each meal. 



American Medicine and Stirgery. 223 

Give at night, tinct. of cannabis indica, 20 drops to procure sleep. 

Friction with salt-water to the spine, with irritating plaster, will do good ; 
avoid strichnine, nux vomica, or electricity in these cases, as they serve to ag- 
gravate the symptoms. 

In cases where the blood is impoverished, and the supply to the cord dimin- 
ished, give 

9,— Hypophosphite Soda 1 

" Calcis j aa. 

Ferri j 

" Potass J 3 ss. 

Syrup Sim plex O i. 

Dose.— One teaspoonful before meals ; shake well. 

fy— Fid Ext Nux Vomica ~\ aa. 

" •' Iris Versicolor > 

" " Xanthoxylum J 3 ss. 

Dose. — 20 drops after each meal. 

Electro-magnetism will do good in these cases, as also salt-water baths, or 
shampooing to spine and affected limbs ; active purgatives should be adminis- 
tered at least once a week, while daily evacuations of bowels should not be 
omitted. 

Constipation aggravates all the symptoms of paralysis. The above treat- 
ment may be alternated with other alteratives, nerve and blood tonics, etc. un- 
der a treatment of this kind, with exercise in moderation, if there is any vitality 
left, we shall soon find improvement. Paralysis, at best, is very hard to control, 
and we must bring to bear both patience and perseverance. 

In the plethoric variety, the practitioner should be very cautious not to recur 
too speedily to the stimulating measures, remembering that for this class, espe- 
cially in the beginning, the disease is one of oppression, and not of debility. 

Even in chronic states of it we may find the pulse hard and corded, with other 
symptoms of a febrile movement, or it may be low from oppression. Under such 
circumstances, renouncing all tonics, we should betake ourselves to evacuation, 
and especially to purgation by elaterium, which will be found to recruit the 
strength by a removal of the disease. The local applications, it may again be 
mentioned, should be made as nearly as possible to the seat of the lesion in the 
nervous centre ; or when the nerve is effected, as nearly as possible to its root. 
Friction may be sometimes employed to the muscles, when the disease seems 
to be primary to them, and there is no excitement. The prevention of paralysis 
is similar to that of apoplexy. 



EPILEPSY. 



The characteristics of an epilectic fit are a sudden loss of consciousness and 
sensibility, with convulsions, lasting a few seconds, followed by spasms of in- 
voluntary muscles. This is succeeded by exhaustion. 

The fits are apt to recur at regular intervals. 

Pathology. — Irritation, conveyed to the nerve centre, may be reflected in four 
different directions : 

1, Upon a muscular nerve, causing contraction of a muscle, or muscles. 



224 Principles and Practice of 

2. Upon &. nerve sensation, giving rise to neuralgia, or nerve ache. 

3. Upon a vaso-motor nerve, causing contraction of blood-vessels. 

4. Upon a tissue nerve, producing secretions, or an alteration of nutrition. 
Under the first head we may class such irritations as the vomiting of preg- 
nancy, convulsions from teething, cough, the result of gastric irritation. 

Under the second head, we have irritation reflected on a nerve of sensation, 
as neuralgia from a wound, after it is healed ; also, from stricture, carious teeth 
and headache, from irritation of the stomach, etc. 

Under the third head, we may class epilepsy — -irritation reflected upon a vaso- 
motor nerve, causing contraction of the blood-vessel supplied by it. Also, the 
excitation of the motor nerves of a gland, in a state of activity, will cut off the 
supply of the bood and check its secretions. 

The nerve centres are merely glands, elaborating nerve food from the blood. 
The nerves being but a ramification of or tributary to carry it to its destination, 
any cessation of the the nervous activity may be produced by contraction of the 
blood vessels by reflex action. From this cause arises loss of consciousness, 
paralysis, numbness, etc. Sudden contraction of the arteries of the brain, by 
whatever irritation reflected, is the starting point of an epileptic fit. 

As a proof of this we have a sudden pallor of the face, as the patient falls. 
The irritation, falling upon the laryngeal, cervical and respiratory muscles, 
bring them into a state of tonic contraction, impeding the arterialization of 
the blood, hence arises the purple hue that succeeds the pallor of the face and 
the general convulsion throughout the frame. In a slight fit without convulsion 
the cerebral artery alone feels the irritation. A less degree of contraction will 
give rise to vertigo. 

Symptoms. — The symptoms of epilepsy are numerous and variable. Some- 
times we have well-marked, premonitory symptoms, such as headache, giddi- 
ness, ringing in the ears, etc. Again, we have a pricking sensation and drawing 
in of the thumbs to the palms of the hands, a sensation of fullness in the head. 

But often, in fact in many of the cases, we have no warning at all. A sud- 
den deathly pallor, a shriek, and the patient falls senseless, and violently con- 
vulsed. These convulsive movements frequently continue for some time, often 
more on one side than the other. The face and eyes are distended, the tongue 
often bitten, difficult breathing, the skin cold and clammy, and perhaps involun- 
tary passage of urine, vomiting, breathing labored and almost suspended, pulse 
weak and irregular. After the attack the patient sleeps soundly and for a day 
or two remains languid, with headache, etc. 

The average duration is from two to five minutes, but may last two or three 
hours. It may occur at any age, but is most common in the young. 

Causes. — Predisposing causes are hereditary taint, strumous or scrofulous 
diathesis, the marriage of persons who are incompatible by temperament or 
consanguinity. 

We have two forms — idiopathic and symptomatic. 

Under the idiopathic form we class various affections of the brain, and de- 
fects in the normal organization, lesion of the meninges, etc. 

Under the symptomatic form, we class those cases that arise as symptoms of 



American Medicine and Surgery. 225 

• 
some other disease, as irritation from indigestible matter in the stomach, worms, 

or any irritation reflected from an irritable brain. Derangement of the circula- 
tion, stimulation, excessive hemorrhages, suppression of menses, wrong modes 
of living, sometimes on scrofulous subjects the suppression of an eruption will 
produce it, veneral excesses, masturbation, pregnancy, fistula, etc., are the exciting 
causes, but they all operate by a kind of reflex action, by which the irritation 
is conveyed to the medulla oblongata, or nerve centre, and produces the symp- 
tomatic variety. 

Diagnosis. — Distinguish from hysteria by the great change of countenance, 
the livid aspect, the fixed or staring expression of the eyes, gnashing of the 
teeth or firmly clinched jaws, foaming of the mouth, and the speedy subsidence 
into a tranquil sleep or heavy stupor. 

Hysteria is accompanied by the. globulus hystericus, by sudden transition 
from laughing to weeping, etc. But the case may be complicated vnth hysteria 
or apoplexy. The disease proceeding from a lesion of the spinal marrow, the 
convulsions are extremely violent, and sometimes of a tetanoid nature, and the 
lesion may sometimes be detected by pressure on the spine. In a lesion of a 
nerve, besides the presence of tenderness, we may also be directed by the par- 
oxysm being perhaps more apt to be preceded by the aura epileptica. 

Its dependency upon an irritation in some remote organ or tissue, must be de- 
termined by the 'associate symptoms which usually characterize such a condi- 
tion. 

Prognosis. — More unfavorable when the disease is primary, or when it super- 
venes after puberty or has long continued. 

Treatment. — To relieve the paroxysm have the head elevated and warmth to 
the extremities, and if the patient can swallow give a half teaspoonful of tr. 
lobelia. 

In every case where we have premonitory symptoms, an attack may be warded 
off by a free use of lobelia and capsicum. In the interval put your patient on 
a regular course of treatment, varied to suit the condition of the patient. 

Among the many remedies in epilepsy, bromide of potass, has stood high 

with all classes of physicians, but while it may give rest, temporary relief, there 

is no certainty about it. One of the best remedies is 

51— Fid. Ext. English Valerian 

Cypripedium 

" Humulus Lup 

" Lactuea [ s llm 

Dilute Alcohol 3 viii. 

Dose. — One teaspornful before each meal. Give also 

fy— Fid Ext. Scutellaria ( aa. 

" " Cimicifuga (S i. 

Mix. — Dose, 20 drops after each meal, and at night give fld. ext. papaver, 
20 drops, just before retiring. Keep the bowels regular with the podophyllum, 
or saline cathartic. Juglans acts well in some cases, as also, pulsatilla and 
sumbul. These should all be tried in succession or alternation. Remember 
the arresting of epilepsy does not imply a cure. You must keep up the treat- 
ment for months after all symptoms have disappeared. 
15 



226 Principles and Practice of 

The above course will arrest any ordinary case of epilepsy. When it has 
some primary or exciting cause that must be removed, all the functions should 
be regulated, and the general health built up with nerve and blood tonics, etc. 

Drunkenness, scrofula, wine, etc., etc., sometimes cause it, as also, excesses 
and solitary vices ; all of these are to be removed, and under the above course 
improvement is rapid. 



INSANITY. 



This is one of the greatest calamities that can befall the human kind. In a 
healthy and active brain, or nervous system, we have three conditions — objec- 
tive ideas which arise in external surroundings ; subjective ideas which are from 
religious or strong impressions, and last impressed ideas, as abstract truths, 
original thoughts, etc. 

An impression made upon any of the senses, is at once telegraphed to nerve 
headquarters, the brain, hence the sense of smell is immediately transmitted 
to the brain ; if the odor is agreeable, the brain approves, and is delighted, if 
the reverse, it is repugnant and disgusting, 

So in the same manner are ideas, thoughts, or instruction conveyed to the 
brain; if this faculty is impaired, memory deficient and incapable of receiving, 
acting, retaining or rejecting, or if at all in a disordered way, then we have in- 
sanity. To define insanity would require a book much larger than this volume, 
and to draw the lines between perfect sanity and insanity is a nice thing, indeed. 
Most of the murders of the present day are attributed, but strange to say, many 
other crimes due to an over-stimulated, or exalted condition of the sense or 
feeling involved, are seldom charged to insanity. We have more cases of par- 
tial insanity amongst us than we are willing to admit. We will proceed to 
mention some of the most prominent symptoms : 

At first we may have only a partial perversion of the intellect, the chain of 
ideas is broken, producing incongruous combinations at variance with reason 
and common sense. We must not jump to the conclusion that this is insanity, 
without other symptoms. Insanity appears under various phases, according to 
the part of the brain affected. Severe cases are slow in developing themselves; 
the prominent symptoms, and those which should excite alarm are headache, 
giddiness, loss of memory, mental confusion, irritable temper, carelessness, 
want of application to usual occupations, lethargy, weakness, desire to sleep, 
tired of life. 

The first intellectual faculty that gives way is the memory, strangeness of 
conduct, imperfect articulation, impaired stomach, obscure thoughts, frightful 
dreams, sometimes complicated with epilepsy, or paralysis. When complicated 
with epilepsy, the conduct of the patient is ferocious and outrageous, but, when 
complicated with paralysis, is quite helpless. When paralysis is a signal or re- 
sult of mental disease, it increases as the power of the mind diminishes. I am 
of the opinion that no form of insanity should be recognized but that mental 
unsoundness the result of disease. There are different forms of insanity. 



American Medicine and Surgery. 227 

MANIA. 

This is a species of special derangement. Patient may be quite rational up- 
on special subjects, seizing upon some topic, passing from one to the other with 
great rapidity, ideas are abundant, erroneous, and obscured, manner wandering, 
sometimes violent and excited. The intellect becomes deranged on all sub- 
jects ; the moral qualities become perverted, and hatred, rage and quarreling 
take the place of better qualities. The patient may be conscious of his iden- 
tity, but the mind operates through a diseased organ, shrieking, crying, laughing, 
emaciation, want of sleep, loss of appetite. We have another class of cases 
which we may term 

PUERPERAL MANIA. 

A form common to women after delivery, usually occupies about four or five 
days. It commences with restlessness, insomnia, pain in the head, and an ar- 
rest of the secretion of milk, sometimes no fever ; in other cases febrile exacer- 
bation, debility, prostration from hemorrhages, tedious labor, some morbid poi- 
son that has depressed vital power ; the delirium is often violent. 

MONOMANIA. 

A derangement upon some particular subject, which constantly occupies the 
mind to the exclusion of everything else. I knew an aged woman once very 
wealthy, who, on the death of her husband, had been left penniless, and ever 
after she was talking law, and of a pending lawsuit which would, when deci- 
ded, restore her lost fortune ; her insanity was harmless, but unfitted her for 
every employment. 

The reasoning power is impaired, but the logic may be good and correct in 
the main, yet your patient never leaves his subject. We have several forms of 
monomania. 

DEMENTIA. 

This is a weakness of intellect from accident, age, or other causes producing 
feeble mind ; ideas few and confused, vague, wandering, memory much im- 
paired, ignorance of time, place, quantity or quality, quick to forget, are unde- 
cided, childish and silly, devoid both of affection or aversion, restlessness, ex- 
citement, scarcely any control over the evacuations, etc. 

IDIOCY. 

Due to congenital imperfection of the brain, mind not developed, ideas few 
and simple, manners foolish, transient bursts of passion, vacancy, articulation 
and gait imperfect, may be blind, or deaf mute. 

Causes. — Insanity is nearly always associated with diseases of the body. 
Mind and body must act in perfect harmony ; this is an immutable law of na- 
ture. In some cases insanity is hereditary, but most cases occur when the brain 
has reached its most active point, and is easily excited by hard study, over- work, 
dyspepsia, some drain upon the nervous system. 

Injuries upon the head, poison, want of sleep, over-exertion, mentally or 
physically, hereditary predisposition, etc. 

Treatment. — The most important consideration is rest of mind and body. 



228 Principles and Practice of 

We want change — change of scene, change of place, change of occupation, a 
proper amount of sleep is indispensable, the greatest possible attention is to be 
paid to hygienic rules. Keep the secretions all in healthy, active condition, the 
skin, liver and kidneys. The sexual organs must be in a healthy condition, and 
in addition to this we must pay special attention to the removal of other dis- 
eases, rheumatism, etc. To meet the mental derangement we would give 

ft— Tr. Cinchona Comp 5 viii. 

Acid Phos. Dilut 5 ii. 

Simple Syrup 3 vi. 

• 

Dose.— One teaspoonful three times a day before meals. 

ft- Fid. Ext. Cimicifuga 1 QQ 

" ,: Sumbul ! aa - 

" " Lactuca [» 

" " Humulus : J 5SS ' 

Dose. — 30 drops in water after each meal, and at night give 30 drops fld. ext. 
scutillaria just before retiring. 

When the brain is diseased, the secretions and excretions are in a measure 
arrested, and we have to give much larger dose than under other circumstances ; 
depleting medicines should be avoided by all means, as they tend to depress 
rather than benefit. 

The treatment of insanity requires special qualifications, and adaptation pos- 
sessed by only a few. Our insane asylums, as a rule, are not calculated to im- 
prove the mind of the patient. Pleasant surroundings, kind, humane treatment, 
a general building up of the whole system, removing as far as possible all 
sources of irritation, physically and mentally ; attention to diet, hygienic rules, 
will do more to restore the mental faculties than any other line of treatment. 
Each case must be treated upon general principles, giving attention to the 
cause upon which it depends. 



CHOREA. 



Chorea, or St. Vitus dance, is a spasmodic affection characterized by an en- 
tire want of control of the muscular nerves over the muscles during the wak- 
ing hours, and this gives rise to irregular, involuntary motions of the voluntary 
motors. It is most common to girls of feeble constitution, or irritable, nervous 
temperament, and usually appears between the ages of six and sixteen. It is 
met with in boys, but more rarely. 

Pathology. — It is due to want of harmony between the white and grey mat- 
ter of the nerve centre, or spinal cord. An irritation without such want of 
harmony could not be productive of the characteristic phenomena of chorea. 
Although we do not know precisely the nature of the pathological condition of 
the brain, it may be presumed to be similar to that of the kindred diseases. 

Symptoms. — In the commencement of this disease we have nervous depres- 
sion and irritability — the involuntary motion begins by twitching of the mus- 
cles of the face, the other muscles follow, until we sometimes have the whole 
muscular system involved. The face sometimes becomes contorted, the artic- 



American Medicine and Surgery. 229 

ulation becomes indistinct, and the temper irritable in the extreme, appetite is 
very irregular, bowels constipated. In some cases only one side is affected, in 
others the whole system is affected. 

Irregular action ceases during sleep, as a rule, though I have had one or two 
cases that even during sleep were moving and trembling. 

The disease may last for months and years if not properly treated, and the 
longer it runs the harder it is to control. Very rarely the respiration is affected, 
and occasionally even the heart is involved. * 

Causes. — Among the exciting causes we have anaemia or impoverished con- 
dition of the blood, worms, teeihing, indigestion, or disorders of the stomach. 
Eruptions of the skin, diseases of the kidneys and bladder, retarded or inter- 
rupted menstruation, sudden change of temperature, secret habits and preg- 
nancy, want of nutritious diet, loss of blood, mental emotions of fear, joy or 
grief — and children of scrofulous diathesis are prone to this among other ner- 
vous disorders. 

Diagnosis. — We must endeavor to determine the location of the primary ir- 
ritation. 

Prognosis. — Little immediate danger, though the degenerations of the disease 
have proved distressing, or even destructive of life. Occurring near the age of 
puberty, a good hope is afforded that the changes effected by that epoch may 
eradicate the affection. 

Treatment. — In treating chorea or St. Vitus dance, if we expect to succeed 
we must make an entire change in the patient. Change of air, of occupation, 
of diet, plenty of exercise in the open air. .Let the diet be highly nutritious — in 
a word, build up your patient as rapidly as possible. The exciting cause must 
be removed at once ; if we cannot determine upon what that depends, we must 
watch our patient closely. The whole nervous system being in a highly excit- 
able condition, and the least over-excitement will often develop this diseased ac- 
tion. In treating this disease, I have found the following indicated in most 
cases : 

P— Iodide of Potass Si. 

Syr. Stillingia Comp 3 xvi. ' 

Dose. — One teaspoonful in a wine glass of water before each meal. We 

would regulate the various secretions by appropriate remedies : 

Ijk— Podophvllin grs. iii. 

Leptandrin grs. iv. 

Mix with sugar of milk and divide into four powders giving one every second 

night. If we suspect worms, give : 

tfc— Santonine .. ..grs. ii. 

at night and follow with the purgative powders as above ; or in pace of santo- 
nine give a few drops of turpentine, and follow with tonics — say forty drops 
of tincture cinchona before each meal. Where we have debility or impoverished 
blood, give syr. hypophosphites. Where we have great excitement and irrita- 
tion of the nervous system we should give : 

&— Fid. Ext. Cimicifuga 

" " Cypripedium 



."I aa. 

. J 5 ss. 



230 Principles and Practice of 

Dose forty to sixty drops three times a day. At night to produce sleep, give 
fid. ext. Scutellaria, thirty drops. 

Electricity properly applied is good in most cases, but I would not advise it 
unless applied by a practical operator. Frequent baths of salt water, warm or 
cold, are advantageous. Purgatives must be repeated at least every second night, 
and given in such dose as will produce free evacuation. We can do little while 
constipation prevails. This treatment will prove effectual in every case if per- 
severed with. 



DELIRIUM TREMENS. 

As is well known, this is caused from the poisonous effects of alcoholic liquor 
acting directly on the brain. Just how it acts in this way, we can only infer 
from the appearance of the brains of persons dissected who have died from this 
poisoning. In these we find induration, a shrinking of the brain in spots, form- 
ing an impassible barrier and cutting off nutrition and the passage of the blood 
through the brain. 

Symptoms. — The symptoms of delirium tremens are too well known to need 
a minute description here. The skin is usually cool and moist, pupil contracted, 
white of the eyes assumes a pale appearance, mental derangement, wild expres- 
sion of countenance, eyes fixed intently upon some imaginary objects, constant 
dodging, and endeavors to avoid them ; going through all kinds of motions and 
with a rapidity astonishing to behold. We have tremors, flabby, moist tongue, 
pulse nearly natural. The mind is wandering and delirious ; general appear- 
ance of debility, sleeplessness ; delirium worse towards night, incessant talking, 
great prostration. All of these conditions depend upon want of circulation in 
the brain, or rather want of nutrition. 

Cause. — Excessive and long continued use of alcohol. This poison has a spe- 
cific action on the brain, first producing slight inflammation of its substance. 
This, long continued, brings about induration and anaemia. 

Treatment. — The undue excitement of the nervous system is rapidly wearing 
out the vital powers, and would, if long continued, lead to final exhaustion and 
death ; hence the indications of treatment are very plain. We must subdue ex- 
citement of the nervous system, which is rapidly consuming the patient. To 
this end I would give lupulin, and I do not believe it has an equal in the mate- 
ria medica. Give it thus : 

#— Fid. Ext. Luimlin S ss. 

Tr. Capsicum 3 i. 

Dose. — Thirty drops every two hours till the tremors stop and the patient is 
calm. We must support the system by stimulants and good nutritious diet ; 
we must purify the system from this alcoholic poison. A partial arrest of the 
functions of the brain is always attended with a corresponding arrest of all the 
secretions of the system. 

The urine is diminished — urea, a terrible poison in itself, is thrown into the 
blood, the bile accumulates and we have in addition to alcoholic, a ureamic 



American Medicine and Surgery. 231 

poisoning of the system. To correct this condition we must give a warm alka- 
line bath. Place your patient in bed, give the lupulin and capsicum or essence 
of Jamaica ginger, plenty of liquid nutritious food. There can be no doubt that 
capsicum is the very best stimulant for deficient circulation in the brain, and 
we often find our patient sleeps soundly after the first dose. It not only has a 
stimulating influence on the brain, but on the pneumo-gastric nerve and in fact, is 
a splendid stimulant, and this with lupulin, is about all that is needed to treat any 
case of delirium tremens. We should give fluid nourishment, beef tea, and 
keep the patient quiet and room dark ; all sources of mental irritation to be re- 
moved, shower baths, cold effusions. 

We shall find ten drops tincture nux vomica very good to establish convales- 
cence, or cimicifuga is good when there is nervous excitement, with threatened 
spasms. To prevent, or cut short an attack of delirium tremens, I would ad- 
vise lobelia. Give it at any stage of the case a teaspoonful dose of the tincture, 
and repeat as often as indicated. 

Establish convalescence on bitter tonics, and prohibit the use of alcoholic 
stimulants. 



COUP DE SOLE1L. (SUN-STROKE.) 

This condition is attributable to two causes : 

1. To a direct want of serum in the blood, the watery constituent being 
drained off by a high degree of dry heat. 

The second cause we attribute to the direct depression of the nervous system, 
interrupting the functions of the eliminating organs, the lungs, liver, kidneys, 
and skin. The blood is imperfectly organized, and being drained of its serum 
it has a tendency to coagulate in the coats of the vessels, and even in the brain and 
heart. The bowels are generally constipated, the liver torpid, and the secretion 
of the urine is diminished. This clotty condition of the blood, or the depression 
on the nervous system, gives rise to faintness, a craving for water, heat, and 
dryness of the skin. We have regular nervous depression, vertigo, fulness in 
the head and chest, pulse quick, irregular feeble and small. 

Symptoms. — These are variable. We sometimes have a sudden seizure, par- 
alysis, shortness of breath, preceded by" languor, lassitude, etc. Paralysis and 
insanity is often a sequel of this clotty, or coagulated condition of the blood. 

Treatment. — In treating this derangement my remedy is water — water locally, 
water internally. Keep blankets saturated in tepid water applied to the whole 
body. Give water to drink, and water as an injection. The blood is deficient 
in the watery principle, hence we endeavor to supply the deficiency by the di- 
rect application of water. Give an emetic of lobelia and capsicum, plenty of te- 
pid water, after the stomach is unloaded. We shall find the administration of 
such medicines as increase the solubility of the blood advisable. Give 

fy— Leptandrin grs. iv. 

Sugar of Milk grs. xx. 

Mix and give the whole at night. Then follow with 



232 Principles and Practice of 

Jpfc— Fluid Extract Xanthoxylum Si. 

Tr. Capsicum 3 ss. 

Aqua O ss. 

Dose. — One teaspoonful before each meal and continue the application of wa- 
ter to the body ; friction over the spine will do good. Give no alcohol. Let the 
clothing be adapted to the temperature of the body — free and easy. 



TETANUS. 



Tonic spasms of the voluntary muscles, the powers of sensation and thought 
remaining unimpaired. Tetanus is divided into different varieties, viz : trismus, 
opisthotonos, emprosthotonos, pleurothotonos. In the first, the muscles of the jaw 
are chiefly affected ; in the second the extensions of the back, producing recur- 
vation of the body ; in the third, those on the anterior part, producing 
innervation ; and in the last, those on the side are principally affected, causing 

lateral curvature. It is divided also into idiopathic and traumatic — the for- 
mer variety being the result of general causes — the latter of external injuries. 
This division has an important bearing both on the prognosis and treatment of 

the disease. 

Symptoms. — Its approach is almost always gradual, the symptoms being de- 
veloped in the following order: Slight difficulty of deglutition and change of 
the voice, an uneasy sensation in the praecordial region ; stiffness in the muscles 
of the neck and jaws. These symptoms having increased to a considerable de- 
gree of violence, sudden painful retractions about the ensiform cartilage, with 
simultaneous retraction of the head occur. Deglutition is painful and difficult, 
and re-excites the spasms. The spasms acquire more and more violence and 
frequency, until the retraction of the head, and rigidity of t.he whole body be- 
come truly frightful. The appearance is terrible, the face pale, bloodless, con- 
tracted brow, skin of forehead is wrinkled, eyes fixed, prominent, sometimes al- 
most bursting from their sockets, at times diffused with tears, intense thirst > 
patient may doze but cannot sleep. The mind is seldom affected, the appetite 
generally remains, and digestion goes on regularly. Costiveness almost always 
attends. The muscles supplied with ganglionic nerves, and those which move 
the fingers, remain free from spasm, until near the fatal termination of the dis- 
ease. The disease usually terminates before the fifth or sixth day — -sometimes 
it continues much longer ; and occasionally it assumes a chronic form. 

Causes. — Various injuries. Contu:-ed, lacerated and punctured wounds most 
apt to produce tetanus. A partial division or laceration of a nerve apt to ex- 
cite it. The introduction of cold, damp air into gun-shot wounds, when casting 
off their slough, favors the development of tetanus. The application of caustic 
to encysted tumors, compound fractures, the insertion of artificial teeth, ampu- 
tation, ligatures including nerves, cutting corns too closely, etc., have all fre- 
quently produced the disease. Cold and damp night air, after fatigue and ex- 
posure to a high degree of atmospheric heat during the day, is the most common 
general cause. Hence its frequency in tropical climates. Atmospheric heat is 



A mericafi Medicine and Surgery. 233 

a powerful predisposing cause of tetanus. Traumatic tetanus generally comes 
on about the eighth or ninth day after the infliction of the wound ; frequently 
not until it is cicatrized. 

Proximate cause. — The original seat of the disease is in the spinal marrow. 
It certainly arises from effusion. This is the true condition, and appears as a 
long standing, spasmodic contraction. This supported by the post mortem ap- 
pearances, and the circumstance that the muscles supplied by spinal nerves are 
almost exclusively affected. 

Prognosis. — Traumatic tetanus, seldom cured. The idiopathic form less 
difficult of cure. The disease always terminates fatally when the pulse rises to 
120 beats in a minute on the first day; if by the fifth day it does not exeed tio 
a favorable issue may be expected. The favorable signs are : a very gradual 
supervention of the disease, abdomen not very hard, bowels easily moved, moist 
and moderately warm skin, sound sleep, an increased flow of saliva, a natural 
expression of countenance. When the majority, or all of these circumstances 
occur, we may entertain hopes of recovery. The unfavorable signs are : a sud- 
den and violent invasion of the disease, great rigidity of the muscles of the 
back, neck and abdomen, violent pain and retraction in the pit of the stomach, 
very hard and retracted abdomen, spasmodic twitches of the muscles of the 
neck and jaws, on firm abdominal pressure hydrophobic symptoms. 

Treatment. — Divide into prophylactic and curative — the former refers to 
the prevention, the latter to the removal of the disease. Wounds or injuries 
from which tetanus is apprehended, should be brought to suppurate as soon as 
possible. For this purpose scarification, free division with the knife, irritating 
applications — such as spirits of turpentine, caustic, etc., are employed. When 
the disease has made its appearance, constitutional are to be used conjointly 
with the local remedies. The most important of these, and the only treatment 
likely to proye effectual, is a combination of lobelia, capsicum, and valerian, as 
follows : 

#— Fid. Ext. Lobelia ) aa. 

" " Vale ian [ 5 i. 

Tr. Capsicum. 5 i. 

Mix. — Give thirty drops every hour, introduce it between the teeth and throw 
it up the rectum at the same time, until complete relaxation is established. If 
this does not seem to act quick enough, give chloroform ; inhale it until relaxa- 
tion is complete, then follow with : 



#— Fid. Ext. Podophylum. 
" " LeptandVia. 



Iris Yersicola J gtts. x. 

Give at a dose. Keep up the relaxation, and then give 

#-Fluid Extract Scutellaria ] aa 

" " Cypripedium i 

Tr. Capsicum | 

' ' Lobelia J Si. 

Aqua S ii. 

Dose. — One teaspoonful every three hours, alternate with, say, twenty drops 

of fluid extract pulsatilla, and every two hours apply ice to the spine, dry cup- 



234 Principles and Practice of 

ping, etc, If you can keep your patient along four or five days, you will be able 
to overcome the disease by absorption of the effusion, and get up a reaction. 
Remember it is a disease that death is the only alternative, and that, if the 
treatment appears heroic, keep in mind the fact it is a disease that will admit 
of no half-way measures. 



HYSTERIA. 



This may be defined as a nervous disorder, assuming various forms, but com- 
monly presenting a paroxysmal character. A most Protean and imitative dis- 
ease. 

Pathology.— An exalted excitement, congestion, or phlogosis of the brain, 
which is either primary or the consequence of an irritation of the spinal marrow 
uterus, alimentary canal, or other part. 

Symptoms. — It may be preceded by various nervous phenomena, prsecordial 
tightness, flatulence, nausea, or vomiting, or may come on suddenly. On the 
latter occasion, the earliest indication is constriction of the chest, pain about the 
flexure of the colon, with a sense of fulness, and a rumbling which advances to 
the stomach, and thence to the throat, occasioning pressure as of a ball lodged 
there, and caWedgto&us hystericus. The preceding symptoms are soon followed 
by coldness and shivering, a fluttering pulse, and such acute pain in the head as 
to be compared to the driving in of a nail, and hence called clavus hystericus 
The chilliness is followed by no reaction. Convulsions ensue, varying from the 
slightest to the most violent. The trunk is contorted backwards or forwards, 
or to the sides, the limbs are agitated, the hands clenched, the sphincter ani firm- 
ly closed, while the sphincter of the bladder may be relaxed, and emit copious 
streams of pellucid urine. During this period there are wild shrieks, incoherent 
expressions, alternations of laughter and crying, and a constricted respiration. 

As the paroxysm subsides, deep sighings or sobbings take , place, eructations 
of wind, a gradual restoration of the senses, but without any recollection of 
the events of the paroxysm ; though sometimes, long after the subsidence of 
the fit. there remains a state of stupor, with flushed face, or, on the other hand, 
a pale, cadaverous appearance, with great languor. There may be either a sin- 
gle paroxysm, or a succession of them for several days. 

Causes. — May occur either in the male or female sex though it is far more fre- 
quent in the latter. It" hardly ever occurs prior to the age of puberty, or in ad- 
vanced life. Single women and young widows are most Jiable to its attacks. 
The predisposing causes are, nervous temperament, heated rooms, reading 
works of fiction, tight lacing, lack of exercise, habitual indulgence in amorous 
desires, nervousness, luxurious living. The exciting causes, mental impres- 
sions, irritation, sudden suppression of menstrual discharge, uterine irritation, 
leucorrhoea. 

Hysteria has long been regarded as dependent on spinal irritation. From 
the extent of the spinal cord, and its connection from one extremity of the 



American Medicine and Surgery. 235 

trunk to the other, and its connection with the cerebral nerves, it must exercise 
an extensive influence on the phenomenon presented by various diseases. 

Diagnosis. — Be careful to ascertain the origin of the disease. Proceeding 
from a uterine, or gastro-enteric affection, it will be probably accompanied by 
symptoms which when duly weighed will indicate the primary source of irrita- 
tion. Being of primary cerebral origin, we find headache, a florid face, vertigo, 
tinnitus aurium ; while its arising from the spine, is denoted by tenderness of 
some portion of the spine, and the violent tetanoid spasms. 

Prognosis. — There have been few cases reported of a fatal issue of the par- 
oxysm. The disease may, however, degenerate into epilepsy. 

Treatment. — The milder attacks are usually treated by the application of 
pungent odors to the nostrils, or the internal administration of the antispas- 
modics. Dashing cold water in the face, with sinapisms to the extremities. 

An emetic almost always restores tranquility, and obviates a renewal of the 
paroxysm. The best emetic will be the comp. powder of lobelia, given in small 
doses, every fifteen minutes until free emesis. 

Purges and enemata, particularly where we suspect irritating accumulation 
in the intestines, or where constipation exists. Nervines and antispasmodics — 
among the best combinations of this class is,— 

Jfe— Fid Ext Lobelia ~) QQ 

" Scutellaria . . c \ ( 

" " Cypripedium ■ J " 

Tr . Capsicum 5 ss 

Dose. — Forty drops in water, once in three hours, when we have premonitory 
symptoms. 

If due to uterine troubles that must have attentidn, and among our best rem- 
edies here are caulophyllum and helonias. 

#— Fid Ext Canlophvllum 1 oa 

" Viburnum I __ 

" " Helonias dioi ! * i 

" " Senecio J ° 

Dose. — Twenty to forty drops three times a day. At same time give the hy- 
pophosphite comp., or cinchona comp. to build up the system. When due to 
spinal irritation, capsicum plaster to spine with active nerve and blood tonics 
will succeed. 



NEURALGIA. 



A disease of comparatively modern origin, but little known a century ago # 
The term neuralgia signifies nerve ache. 

This disease may affect any of the nerves in the body, and being seated in 
the nervous centre, the pain darts along the nerve to its minute ramifications, or 
conversely, arising at the branches, may be reflected at the centre. But in its 
course, it is apt to entangle other nerves of the same, or a different class, and 
render the aspect more complex. 

Pathology. — The disease though having generally a local, may have also a con- 
stitutional origin. It seems certain though inflammation of a nerve, or nerve 



236 Principles and Practice of 

center may supervene upon neuralgia, that yet it is not an essential ingredient of 
it. Still the disease, may commence in a neuritis or myelitis, or phrenitis, which 
may be exchanged for neuralgia, or their may be inflammation at the root of a 
nerve, and in the branches a mere neuralgia, which may enjoy an indefinitely pro- 
tracted and independent existence after the reduction of the neuritis. The 
nature of the pain and the effect of the medicines, are much diversified by the 
affection. It seems to be seated, however, only in the nerves of sensation, and 
is associated with a state of exceedingly exalted sensibility — a state the oppo- 
site of that of palsy. 

Symptoms. — The attack may come on without any premonition or may be 
preceded by dyspeptic, uterine, or arthritic disturbance. Decidedly paroxysmal 
in the commencement, the paroxysms observe the laws of periodicity, in imita- 
tion of an intermittent. When chronic, however, it is less paroxysmal. Imme- 
diately precursory, are often to be noticed a sense of chilliness, slight disorder 
of the stomach, pallor, and sometimes a sense of formication, or the aura epi- 
leptica. The paroxysm is made up of transient paroxysms, between which there 
are commonly remissions of comparative ease. The pain shoots along the 
nerve, following its distribution, and is sometimes terribly severe. The part is 
so tender that the slightest touch cannot be tolerated — even less tolerated than 
firm pressure. Redness of the part sometimes occurs. Twitching of the adja- 
cent or remote muscles, is occasionally observable. The circulation is little 
changed. 

The duration of an attack varies from one to two hours to several days. The 
attack may not return for a week, month or year. Neuralgia most frequently 
assails the three divisions of the fifth and the facial portion of the seventh pair 
of nerves. It often attacks the intercostal muscles, those of the shoulder, loins, 
hips, the large articulations, the scalp, mammas and testicles. The brain, too, 
as well as other viscera, is subject to it. It may be confined to a spot no larger 
than a pea. 

Causes. — Predisposing — most incident to the period of life between forty and 
sixty ; to the female with a delicate, irritable, or shattered constitution. But ex- 
ceptions to the last statement are numerous. It is apt to attack in a mitigated 
form, girls at the age of puberty, or a little later. Mechanical injuries cf nerves 
from wounds, or from the pressure of spiculse of bones or tight lacing ; the 
chemical action of the fluids in caries ; dental irritation in facial neuralgia, mias- 
mata, excessive venery, or masturbation, dyspepsia, or lesions of any of the vis- 
cera (though it is probable that many cases attributed to these causes are really 
founded in atonic, or misplaced gout), anaemia. Exciting — exposure to cold, 
moisture, or a draft of cold air, undue corporeal or mental exercise, the emo- 
tions, or slight mechanical disturbance. 

Diagnosis. — Distinguished by the acute pain darting along the nerves, its oc- 
currence in paroxysms, and the absence of inflammatory signs. It bears the 
closest analogy to neuritis, or inflammation of a rrbrve, and particularly in case 
of the tooth. But this may be distinguished from genuine odontalgh, by its be- 
ing deep-seated, more obtuse, permanent, ultimately followed by swelling of the 
cheek an j gums, and by its ending in suppuration, etc. It is distinguished 



American Medicine and Surgery. 237 

from rheumatism by the difference of the predisposing and exciting causes, the 
difference of the seat of the pain, the absence of fever and inflammatory signs, 
its not impairing the construction or structures, even when protracted, and the 
different effect of remedies. It is very important, though sometimes difficult, to 
elucidate the source :>f the disease. 

Emanating from the head, the qase is preceded by giddiness or other uneasi- 
ness of the head, disorder of some of the senses, congestion or increased action 
in the vessels of the brain, with a sympathetic affection of the liver or stomach. 
The symptoms of the superior cervical division of the spinal marrow, are pain 
in the scalp, shooting in various directions up the occipi;al even to the frontal 
portion, or laterally along the temples over the face, or sweeping behind the 
ears, or around the lower jaw, productive of rigidity of the muscles, impeding 
its movements and those of the head. 

In an implication of the inferior cervical portion, the pain is seated in the su- 
perior part of the chest, about the clavicle or scapula, or it runs down the arm, 
sometimes even to the fingers ; or passing forward, the superficial integuments, 
or the mammas in females, may be involved in exquisite soreness, or intense, 
darting pains. The upper part of the dorsal division being, affected with many 
of the symptoms just mentioned, it is more strikingly characterized by pain in the 
intercostal muscles, or margin of the ribs, or sternum, or epigastric region, or 
integuments behind the chest, the acuteness of pain being occasionally ex- 
changed for dyspnoea in various degrees. 

The lower dorsal division being affected with some of the preceding phenom- 
ena, we have a sense of constriction across the waist, and great tenderness and 
darting pains in the parietes of the abdomen. In disease of the lumbar and sac- 
ral section, there is a dull ache, or acute pain in the muscles of the loins, and 
those of the hips, with a pain shooting down the low T er extremities, and the tot- 
tering gait of an inebriate. The ganglia, or branches of the sympathetic being 
involved, we have depravations of function or true neuralgic pains of the or- 
gans deriving their nerves from this source. Thus result palpitations, spasmod- 
ic asthma, angina pectoris, cramps, colic, gastralgia, etc. Connected with these 
disturbances, we may find great vitiation of the secretions, as in pyrosis, the 
diabetic discharge, etc. But generally in protracted cases one set of nerves im- 
plicates another. This is particularly the case of the spinal and ganglionic 
nerves. The former, indeed, have seldom a distinct affection. In colic is ex- 
emplified the implication of the nerves' of the back, the pain in which is as great 
as that in the bowels. The most certain te?t of spinal disease is, undue sensi- 
bility betrayed by pressure, or percussion of the vertebrae, or sponging with hot 
water. 

Prognosis. — Rather difficult of cure, especially in old cases but under our A- 
merican system is favorable and a cure is readily effected when not due to spi- 
nal lesion, or some extraordinary irritation. Those are most favorable, which 
are seated in the spinal marrow ; and those seated in the ganglionic nerves the 
least so, especially when connected with depravation of the abdominal viscera. 
The disease, however, cannot be regarded as fatal, and it often disappears 
spontaneously, or under the influence of some new disease, especially an erup- 



238 Principles and Practice of 

tive one. or a revoluion in the mode of living, or merely the shock of a mental 
emotion. 

Post-Mortem. — In most instances no appreciable lesions have existed. In 
many the lesions were probably the cause instead of effect of the disease. In a 
few cases the vessels of the neurilemma were found preternaturally turgescent ; 
and the nerve had an unnatural floridness, was thickened, but wanted the effu- 
sion of serum, lymph, or pus, with the general changes of structure incident to 
neuritis. 

Treatment. — The treatment of neuralgia resolves itself into curative and 
prophylactic. When called to a patient suffering from a severe attack of neu- 
ralgia, we should order an emetic of the comp. powder of lobelia. When we 
have free action of the emetic, follow with alcoholic vapor bath, then give : 

I#- Podophyllum grs. ii. 

Leptnndrin grs. iv. 

Bitartru,te of Potash 5 i. 

Divide into four powders and give one every six hours until they operate. 
During the continuance of the pain give : 

# -Fid. Ext. Lactuca .... — '. ) aa. 

" " Humulus J 3 ss. 

Dose. — Twenty drops every two hours. This will give rest, and if the neu- 
ralgia has assumed a periodic form, we should give the emetic daily, say two or 
three hours before the time of its return, and in the interval give : 

Ifr — Sulphate Quinine 1 aa. 

Prnssiatc Ferri J grs. xv. 

Pulv. Capsicum grs. x. 

Make ten powders and give one every two hours until five are given. To 
prevent a return and make a permanent cure, we would put the patient under 
the influence of an active alterative, as : 

Jfc— Syr- Stillingia Comp 01. 

" Iodide Potass Si. 

Dose. — One teaspoonful before each meal. After meals the fid. ext. cimicifu- 
ga, twenty to thirty-drop dose. If connected with anaemia or a low or debili- 
tated condition, instead of the stillingia and iodide, we would give : 

P—Tr. Cinchona Comp , 8 viii. 

Acid Phosphoric Dil .- 3 ii. 

Syrup Simplex 5 vi. 

Dose. — One teaspoonful before meals. After meals ten drops of tinct. nux 
vomica, or fid. ext xanthoxylum. Keep the bowels regulated and remove all ex- 
citing causes, building up the whole system, equalizing the circulation, aiding 
digestion and assimilation. 



American Medicine and Surgery. 239 



CATALEPSY. 

This remarkable disease of the brain or nerve center, is characterized by a 
sudden deprivation of sense, of intelligence and voluntary motion. We find 
patients retain the same position during the whole paroxysm, as that they held 
when first attacked, or in which you place them, during the continuance of the 
fit. A single attack or seizure may last from a few minutes to several hours or 
days. These attacks are intermittent, without regard to periodicity. 

Symptoms. — There may be some premonitory symptoms— headaches, muta- 
bility of temper, yawning, vertigo, palpitation, slight spasms, confusion of 
mind or sense ; but usually the seizure is sudden, and without warning or prep- 
aration ; the eyes are fixed, sometimes open, sometimes shut, pupils dilated. 
Restoration usually occurs just as suddenly, accompanied with sighing, pain 
and confusion of the head, with no recollection of what has occurred. No effort 
to restore consciousness is effectual. Nervous and hysterical women are more 
liable to its effects, but men are not exempt from them. 

Causes. — Predisposing — anything that diminishes vital powers and increases 
the susceptibility of the nervous system, such as depressing passions, hereditary 
debility, intense mental labor, scrofulous taint, mercurial or venereal poisoning, 
hereditary or congenital. 

The exciting causes are severe mental emotion, fright, long mental applica- 
tion, excesses in venery ; and in females sometimes due to suppression of the 
menses, and inflammation of the uterus and ovaries. 

Diagnosis. — Catalepsy differs from ecstacy, somnambulism or clairvoyance. 
Catalepsy is produced by a diseased condition, while the others are due to, and 
produced by, voluntary effort ; absence of mind is a mild form of catalepsy. 
Mesmerism and spiritualism are also species of the same. •» 

Prognosis. — Our prognosis of catalepsy is that that there is little danger in 
the largest proportion of cases — it may terminate in apoplexy, insanity, or soft- 
ening of the brain. It is often connected with some organic affection of the 
brain. 

Treatment. — All treatment, to be successful, must be directed to the removal 
of predisposing causes, and avoiding the exciting causes. We should give the 
alterative syrup— full dose— three times a day. 

Give, also, in connection, tonics, hydrastis, cimicifuga or cinchona, half hour 
after meals, with fifteen drops of tinct. nux vomica at bed-time. I have found 
hot baths three times a week, with the following, act well : 

fy— Acid Phos. Dil 3 ii. 

Fid Ext. Cypripedium 3 ii. 

Syrup Simplex 3 xii 

Dose. — One teaspoonful before each meal. Give half an hour after meals, 
fld. ext. Scutellaria, twenty drops. 



240 Principles and Practice of 



CONVULSIONS. 

This is a derangement of the nervous system. In some cases we can trace 
them to some cerebral disorder, and in others we have them developed without 
any apparent connection with any disease. We may divide convulsions into 
two classes : 

1. Convulsions depending upon some lesion of the brain or its appendages. 

2. Convulsions without primary lesion, or change of structure, originating in 
sympathetic or reflex irritation. The sudden, spasmodic, involuntary action of 
the muscles in this condition, depends upon some derangement or disease. In 
the epilectic form of convulsions, we have reflex irritation, or some defect it 
may be, at a remote part of the brain. Convulsion affects the whole muscular 
system, comes on in paroxysms, and attended wi:h unconsciousness. In some 
cases the contractions are partial, of long duration, and the muscles assume a 
hard, compact feeling. This is termed tonic spasm. In other cases we have alter- 
nations of relaxation and contraction. These are termed atonic spasms. 

Symptoms. — We shall, doubtless, be able to detect a long list of premonitory 
symptoms. Chief among these are ill-temper, sudden starting in sleep, restless- 
ness, sudden screaming during sleep, rapid change of complexion. During den- 
tition, we will have heat and redness of the gums, fever, vomiting, morbid ap- 
pearance of the stool, acidity of the stomach, eyes roll upwards, twitching of 
muscles of the face, breathing hard and laborious, twitching of different parts of 
the body, clinching of the fingers and contraction of the feet, livid appearance 
around the mouth, dark ring around the eyes. All these symptoms, however, 
may be absent, and the convulsions come on of a sudden, or with just the 
twitching of one limb. Du r ing the attack there is a distortion of the features, 
pallor, or lividity of the face, starting or protuberance of the eye-balls, insensi- 
bility of the pupils to light, grinding and gnashing of the teeth, protrusion of 
the tongue, involuntary evacuation, labored breathing. The attack is usually 
followed by a tendency to sleep. 

Causes. — There may be organic disease of the nervous system ; may have its 
origin in gout, rheumatism, syphilis, vaccination, a want of circulation of blood 
to the nerve centre, as in anaemia, or scrofula, but the greatest number of cases 
are due to reflex action, from the teething or swollen gums of children, derange- 
ment of the stomach and bowels, such as indigestion or acidity ; intestinal irri- 
tation, such as worms, hard, unripe fruit, disease of the kidneys, uraemea, or 
predominance of uric acid in the blood, pregnancy, liver derangement, absorp- 
tion of bile, morbid state of the blood, as in small-pox, scarlatina, measles, 
mental emotions, violent whooping cough, miasmatic poisoning of the system. 

Prognosis. — Favorable, unless connected wiih some severe, or organic disease 
of the brain, heart, etc. Persons subject to convulsions should be carefully 
watched, and every means adopted to prevent a return of the attack. 

Treatment. — Our treatment, during the paroxysm, should be prompt and de- 
cisive, loose the dress, especially should every thing be loosened around the 
neck and chest. 



American Medicine and Surgery. 241 

Place the patient on the back with head well elevated, give plenty of fresh 
air. If you can get the patient to swallow, give one teaspoonful of tinct. lobe- 
lia with ten drops tr. capsicum. Repeat the lobelia alone every five minutes, 
until the muscular system is relaxed. 

If he cannot swallow, give the lobelia as an injection — enough to produce re- 
laxation — and we may safely keep the patient under its influence for several 
hours. Cold to the head when the face is livid and the head hot. Mustard 

water to the feet, or tne following will be found excellent : 

• 

^fc— Aqua pura O i. 

Muriate of Ammonia 3 i. 

Nitrate of Potassia 5 ss. 

Aqua Camphor 5 x. 

Chloride Soda 5 ss. 

Saturate a cloth and keep the back partbf the neck or head constantly wet 
with the same. Lobelia, cold, or ice to the spine, warm salt water, friction to 
the extremities, or the cautious administration of chloroform, if all other means 
fail to relax. If for teething and the gums are swollen and irritated, scarify the 
gums and regulate bowels, skin, etc. Give the syrup hypophosphite comp. in 
teaspoonful dose three times a day. Should we suspect worms give spirits tur- 
pentine, or pills of santonine. If due to striking in of measles, scarlet fever, etc., 
we must give comp. tinct. serpentariatoget up an action on the skin. Warmth, 
alkaline baths, are advisable. In a word the general treatment in the interval 
should be tonic and alterative, just such as the condition of the patient seems to 
demand. 

In every case our efforts must be directed to the removal of the cause upon 
which the convulsions depend. All remedies that diminish the irritation, 
and thereby remove the cause of reflex action and irritation will do 
good. Purgatives are indicated in full habits, but are rather debilitating where 
there is a pale, unhealthy appearance of the skin. In these cases the hvpophos- 
phites are excellent. 



MYELITIS. 



Inflammation of spinal cord. This is excited by wounds, contusions, damp, 
cold, etc., and the tendency is to terminate in softening, which is more com- 
mon than atrophy or degeneration. 

Symptoms. — Constant and severe pain in the back, increased by motion, spas- 
modic contraction, or rigidity of muscles, followed by paralysis, fever, diminished 
secretions, etc. The pain is increased by heat or the application of hot clothes, 
etc. We may have connected with it, deep-seated headache, convulsive move- 
ment, inarticulation, lock-jaw, difficulty of swallowing and breathing. The ac- 
tion of the heart is irregular, paralysis in some form. 

In softening there is numbness in the extremities, a sense of pain in the 
back, local tenderness on pressure, gradual loss of sensation in the limb. The 
recovery from spinal softening is rare and only effected by diligent treatment. 
16 



242 Principles and Practice of 

Diagnosis. — Death sometimes occurs from cessation of respiratory nerves. 
The inflammation, if limited to the portion near the head, will produce difficulty 
of swallowing and breathing, impossibility of raising the head, a sensation of 
pins and needles in the upper extremities. The symptoms vary according to 
the par,t involved. If the disease is seated in the middle of the spine, we have 
pain in that part affected, n imbness in fingers and toes, convulsive twitching 
movement of trunk, paralysis of lower extremities, etc. If the lumbar region is 
affected we have paralysis of the limbs, retention of urine, involuntary stools, 
etc. 

Treatment. — Counter-irritants along the spine, salt water bathing, and apply 
the irritating plaster, give an emetic of lobelia comp. and follow with an alco- 
holic vapor bath, then : f 

9j— Podophyilin grs. i. 

Leptandrm grs. ii 

Sugar of milk grs. x 

Give the whole at night. Equalize the circulation by giving : 

Jt— Fid. Ext. Serpentaria ) 3 aa. 

" " Lobelia > 

" " Asclepias ) ss. 

Dose. — Thirty drops in water after each meal. Follow with : 

Jt— Comp sys Stillingia 3 viii. 

Iodide potass 3 ss. 

Dose. — One teaspoonful before each meal. The general treatment will be the 
hypophosphites, salt wa er bathing, friction, bracing tonics, good diet. These, 
if they do not cure, will retard the progress of the disease. 



SPINAL IRRITATION. 

An irritation of spinal cord reflected from some remote organ, characterized 
by pain in the spinal cord. 

Symptoms. — Pain in the spinal column, extending to the head in some cases, 
the pain is always aggravated on pressure, a false step or sudden movement ; 
sometimes amounts to numbness, spasm, or loss of muscular power. The ir- 
ritation often extends to the whole body, involving both the nervous and mus- 
cular system. There is usually a feeling of constriction about the chest. I have 
met with cases of irritation of the dorsal or central portion of the spine, where 
the pain would be referred to the side just below the breast (mamma). We 
can sometimes detect a tenderness by pressure upon each process in rotation, 
but very often there is little external symptom of the true nature of the case. 

Causes. — Spinal irritation is usually met with in women, as a result of some 
uterine derangements ; inflammation of the uterus, profuse and exhausting se- 
cretions, excessive menstrual flow. In the ma'e it may arise from rheumatism 
or gout, nervous exhaustion, etc. The exciting causes are mental worry, ex- 
cessive venery, alcoholic liquors, cold, etc. 

Prognosis. — The prospect of a cure depends upon the extent of the irritation, 



American Medicine and Surgery. 243 

and our ability to remove the cause. If the vital powers are not too low we 
can cure, and in every case palliate. 

Treatment. — This will depend upon the cause. If due to uterine trouble 
that must be attended to ; if rheumatism then the treatment directed under that 
head. For spinal trouble apply a capsicum plaster over the whole spinal col- 
umn, and give internally : 

J^t— Fid. Ext Serpentaria . ~| aa. 

" " Asclepias Tub J 5 ss. 

" " Lactuca 5 i 



Dose. — Thirty drops once in three hours. A lotion or liniment 

) aa 

J5i. 
,.~\ aa 

. . j 3 ss . 



l$i— Tr. Arnica ) aa 

" Hyosciomus 

" Aconite Fol 

" Belladonna ~) aa 



Chloroform 



Rub well in over the spine. 

This is a poisonous compound, and, while valuable to relieve local pain, 
should be labeled so as to prevent a mistake in its use. It acts well in all neu- 
ralgic affections sparingly applied, but well rubbed in. 



SPINAL CURVATURE. 

This is met with in three forms : 

i. Posterior curvature is a curve from within outward, producing an elevation 
of the spine — a true hunch-back variety. 

2. Anterior curvature, from without inward, throwing the breast or chest for- 
ward and upward. « 

3. Lateral curvature, which is usually in the form, or rather assumes the 
shape of the letter S. 

Symptoms. — -The most observable symptom is a projection of one shoulder 
above the other, with a peculiar twisting gait when walking ; sometimes com- 
plams of pain or weakness in the opposite side, and there is generally a debil- 
itated appearance. One shoulder and one side of the chest is always elevated 
over the other. 

Causes. — Lateral curvature is often caused by position or occupation, the using 
of a hoe, or any thing that throws the weight habitually to one side. This, 
coupled with weak muscles and ligaments, will soon produce curvature. It is 
generally the result of a feeble vitality, scrofulous or tuberculous diathesis, 
coupled with want or privation. 

Diagnosis. — Posterior curvature, the curve is usually about the middle or 
center of the spine ; slight curvature may result from the habit of stooping, or 
leaning forward while reading, writing, etc. 

Anterior curvature produces quite a singular appearance to the observer, and 
when occurring in the dorsal vertebrae, causes the chest to assume the appear- 
ance of a protuberance. 



J244 Principles and Practice of 

Lateral curvature will appear distinctly in holding a straight line at the upper 
cervical vertebrae and noticing the deviation from that to the lowermost part of 
-the spine. 

Prognosis. — Lateral curvature in children, is amenable to treatment, and ex- 
cept in cases of extreme debility our prognosis will be favorable. Posterior 
curvature is not so easily managed, but if all the circumstances are favorable it 
may be overcome — at least arrested. Anterior curvature is incurable and treat- 
ment amounts to nothing in this class of cases. Fortunately they are very 
rare. 

Treatment. — The best plan of treatment is to apply Kolb braces, daily fric- 
tion with warm salt water, or capsicum liniment. Constitutionally, the syrup 
hypophosphites comp. before meals with cinchona comp. after meals. Rest 
and the recumbent position is absolutely necessary to success. The treatment 
should be commenced on the first appearance of the disease, and the position 
of the patient when lying in bed should be looked to, having them on the back 
as far as practicable. Keep all the secretions in a healthy condition if possible. 
A general building up treatment is required in lateral curvature. 



SPINAL MENINGITIS. 

Acute inflammation of the membranes of the cord may terminate in resolu- 
tion, or in effusion of serum, or in suppuration. The morbid action when 
acute may be associated with disease of the cerebellum or of the cerebral 
membranes ; while chronic, it is mostly associated with caries of the vertebrae. 

Symptoms. — Inflammation of the meninges of the cord, is attended with acute 
pain, often of a burning character, extending along the spine, stretching into the 
limbs, aggravated by motion or pressure, resembling rheumatism ; rigidity or 
tetanic contractions of the muscles of the neck and back amounting to opis- 
thotonos ; paralysis of the lower extremities, which gradually extends upwards 
as the effused serum increases in quantity; a feeling of constriction in the neck 
back and abdomen ; suffocating sem-ations ; retention of urine ; obstinate con- 
stipation. Males are more prone to the disease than females. 

Causes. — Exposure to wet' or cold, where the rheumatic diathesis remains latent 
in the system, mechanical injuries, etc. 

Prognosis. — Unfavorable when we have a strumous diathesis. 

Post mortem appearances are : great congestion, effusion of serum or pus, or 
perhaps softening of the cord. 

Treatment. — We should use active counter-irritants over the spine. The ir- 
ritating plaster with salt water bath and friction of the whole body. 

J*— Fid. Ext. Serpentaria ~) aa. 

" " Asclepias > 

" " Lobelia j 3 ss. 

Dose. — Thirty drops every three hours. If your patient is restless and pain 

great, give : 

^t— Fid. Ext. Sumbul ) aa. 

" " Lupulus )3ss. 



American Medicine and Surgery. 245 

Dose. — Twenty drops every hour until rest is obtained. Build up the whole 
system. For this purpose the hypophosphites where there is debility ; syrup 
stillingia comp. with iodide potass when we have rheumatic diathesis. 



CONCUSSION OF THE SPINAL CORD. 

The spinal cord is liable to concussion, and from its connection and intimate 
relation with all the other nerves of the body, we are liable to have a long train 
of evils follow. We may have it latent in the system for years before its symp- 
toms are developed. I once had a case of paralysis, result of a fall three years 
previous. Slight concussion may be demonstrated by a pricking sensation, as of 
pins and needles in the hands, feet and limbs ; stiffness, w 7 ant of elasticity of 
step, extreme sensitiveness, etc. 

Treatment. — Perfect rest in the recumbent position. 

&— Fid. Ext. Lobelia ] 

'• " Asclepias. .. ,' aa " 

" " Xamlioxylium ' 

" " Serpentaria J 5 SS- 

Dose. — Thirty to forty drops before each meal, and twenty drops of fld. ext. 
cimicifuga after meals. This, with rest and a nutritious, unstimulating diet will 
meet the indications in nearly every case. 



FUNCTIONAL DISEASE OF THE NERVE. 

Our great aim in treating disease should always be to assist the natural effort, 
or diminish the intensity and the natural reflex excitability of the centres. 

Suppression of causes of peripheral irritation. Under this head we may class 
the local application of narcotics, the application of ice, and the thorough de- 
struction of a wound of a poisonous nature by caustic potass or actual cautery. 
We may be justified in resorting to caustic in poisonous wounds, the removal 
of decayed teeth in neuralgia, removal of tumors pressing upon certain nerves, 
in fact, any thing which keeps up irritation or causes irritability, as in epilepsy, 
tetanus, hysteria, and hydrophobia. 

Treatment. — Our best remedies to diminish action — lactuca, Pulsatilla, scu- 
tillaria and cypripedium : 

Jjfc— Fid. Ext. Lactuca ") aa. 

" Pulsatilla \ 

" " Scutillaria J 3 ss. 

Mix — Dose. — Thirty drops in one-fourth wine glass of water three times 
a day : 

#-Fld. Ext. Cypripedium ") 

" Humulus * I aa " 

" •' Sumbul [ j.. 

" " Lactuca J 5 

Holland Gin 3 xii. 

Dose. — One teaspoonful in sweetened water, before each meal. At night 
give : 



246 Principles and Practice of 

fy— Fid. Ext. Guarana 5 i. 

Aqua S viii. 

Dose. — One teaspoonful at bed-time. In hydrophobia and lockjaw, we would 
use electricity, applying the positive pole to the spine and negative over the pit 
of the stomach. 

Sleep is an important consideration when the nerve centers are highly excited, 
and in these cases we shall find nothing better than the course indicated above. 



CEREBRAL HEMORRHAGE. 

Cerebral hemorrhage is indicated by paralysis on one side of the body, and es- 
pecially on the side opposite that on which the effusion has taken place. The 
sense and intellect may not ±>e effected ; the patient may fall soon, but this is 
from the paralysis, and not from sudden loss of consciousness and sensibility as 
in apoplexy. There may be sudden loss of power without loss of conscious- 
ness. If the bleeding continues apoplexy may supervene and death result. 
Many cases recover under proper treatment. 

Treatment. — Free use of purgatives, irritating plaster over the nape of the 
neck. Use counter-irritants; rollers spread with mustard, should be applied 
from the toes to the knees ; give diaphoretics and diuretics, so as to get up free 
action on skin and kidneys. As soon as the hemorrhage h^s stopped, put your 
patient on the compound syrup of frostwort before meals, with iris versicolor 
after meals, say : 

R— Comp. Syr. Frostwort O i. 

Iodide of Potass ' 3 i. 

Dose. — One teaspoonful before each meal : 

Jt*— Fid. Ext. Iris Versicolor ) aa. 

Tr. Sanguinaria 1 3 ss. 

Dose. — Twenty drops in one-fourth wine glass of sweetened water after 
meals. 



CEPHALHEMATOMA. 

This is a bloody tumor the result of pressure, appearing immediately. It is 
always found between the bones of the skull and pericranium. We have met 
wLh them from the size of an egg to that of an orange. It is usually formed 
on one or both sides of the head, and consists of a soft, circumscribed swelling 
fluctuating on pressure. 

Treatment. — In most cases we need not interfere, as nature is equal to the 

emergency of correcting this trouble, and the tumor disappears by absorption. 

It may be aided and hastened by the following : 

J£ — Muriate of Ammonia Si. 

Bromide of Ammonia 3 ss. 

Aqua Oss. 

Dissolve, and keep a piece of lint saturated with this constantly applied. 



American Medicine and Surgery. 247 



COCCYODYNIA. 

This is a pain, soreness or tenderness, just at the end of the spinal column 
(coccyx), the result of falls or blows, violent exercise on horseback, and tedious 
labor in women advanced in life. The inflammation sometimes extends to the 
muscular attachments of the coccyx, or point of the bone. 

Symptoms. — In this affection the slightest movement which stretches the lig- 
aments about the parts causes severe pain : as sitting, riding, walking, stool, 
sexual functions ; even the menstrual flow aggravates it. It sometimes appears 
as a sympathetic affection, reflected from ovaries or uterus. 

Treatment. — This must be directed to the removal of the cause. Should it 
be due to rheumatism, the treatment directed under that head ; if due to nerv- 
ous irritation, we shall find the comp. tincture cinchona and phosphoric acid ad- 
visable, with ten drops tincture nux vomica half hour after meals ; when it pro- 
ceeds from uterine irritation, give iodide potass, as follows : 

fy— Fid. Ext. Helonias S ii. 

Iodide Potass % ss. 

Comp. Syr. Frostwort Oi. 

Dose. — One teaspoonful before each meal. Use a lotion of the following over 
the affected part, twice a day : 

fy— Tinct. Belladonna 1 

" Hyosclamus ' aa " 

" Aconite Fol {_.. 

" Arnica J 3 11# 

Shake well and apply with a flannel cloth, using considerable friction. The 
patient should be kept quiet in bed for a few days, regulating the bowels with 
some mild cathartic. 



HYPOCHONDRIA. 

This is a disease caused from reflex action. Functional derangement of the 
liver, bowels, stomach, or kidneys, operate painfully upon the nervous system, 
producing disorders of the intellect, inactivity and impaired condition of the 
mind. 

We have languor, lassitude, want of resolution, and to sum it up, if you want 
a perfect specimen of misery and woe, you need ask for no other than a hypo- 
chrondriac patient. They are expecting a terrible disease, death is at the door, 
all that makes life tolerable is soon to be taken away, and last, though not least, 
they are going crazy. 

Treatment. — The most efficacious treatment, is to regulate the system — the 

secretions of the liver and kidneys. To this end we must inculcate exercise in 

the open air, attention to diet, bathing in salt-water. Tea, tobacco, liquors of an 

ntoxicating nature should be dispensed with. We would give pills of podo- 

pbyllin compound every night ; say one at a dose, and would follow with 



248 Principles and Practice of 

syr. hypophosphites, soda, lime and iron, one tablespoonful before each meal. 
After meals give : 

fy— Tinct. Nux Vomica ") aa. 

Fid. Ext. Xanthoxylum > 

" Dioscorea j 3 ss. 

Dose. — Twenty to thirty drops on retiring. Salt-water bathing, regular hours ; 
in a word, keep the mind employed and observe the hygienic laws most condu- 
cive to a good digestion. 



HICCOUGH. 



Spasmodic contortion of the diaphragm, due to indigestion, nervous disorder, 
exhaustion, etc. No matter from what cause, it is a symptom of irritation of the 
gastric nerve. Hiccough sometimes becomes quite trouolesome, continuing for 
hours at a time. 

Treatment. — If due to indigestion, the following will relieve: 

P— Bicarbonate of Soda 5 ss. 

Aqua i. 

Dose. — A wineglassful every fifteen minutes. When due to nervous derange- 
ment, give a tablespoonful of tincture of valerian. Peppermint will often relieve, 
and is especially adapted to infants. Usually any thing to suddenly excite the 
patient will relieve at once. I have succeeded in several cases after all other treat- 
ment had failed, with the following : 

Jfc — Tr. Cinchona Comp ~) aa. 

Flud. Ext. Cypripedium > 

Glycerine J 3 ii. 

Acid Phos. Dil 3 ss. 

Dose. — One teaspoonful once in three hours till relieved. 



HYDROPHOBIA. 



Hydrophobia is a disease usually brought on by inoculation of the saliva of a 
rabid animal, appearing in from twenty to sixty days after the bite. In a few 
instances it has remained in the system for years, finally breaking out with full 
force under the influence of some depressing agency. 

Symptoms. — When about to break out the bitten part assumes a livid appear- 
ance, is swollen and painful, pains darting.from the wound with a burning sen- 
sation. Rigors, lassitude, depression, anxiety, watchfulness, giddiness, irritable 
temper, eyes red and brilliant, very sensitive to light, uneasy sensation in the 
stomach, constriction of the chest, difficulty of swallowing, oppression and 
shortness of breath ; spasm of the larynx, secretion of a viscid saliva ; the 
patient continually hawking and spitting, mouth and throat intensely dry, and 
unquenchable thirst, which he cannot allay on account of the spasmodic con- 
traction of the throat, etc., when drink is offered. As the case progresses the 
respiration is more difficult, the voice changes, the pulse underanged, yet the 



American Medicine and Surgery. 249 

skin is hot and dry, spasmodic twitching of the body, pain that beggars descrip- 
tion extends up the spine to the head ; the countenance becomes pale and hag- 
gard, and the eyes sunken, heart palpitates, muttering delirium, inclination to 
bite, greatest anxiety and uneasiness, sinking of the pulse, loss of voice, clammy 
sweat, convulsions and death. The poison when it comes in contact with the 
human tissues, has the effect to poison the nervous system, and the irritation 
speedily affects the whole muscular system. The heart, lungs and brain soon 
suffer and death is the result. 

Diagnosis. — There is no mistaking hydrophobia for any other disease, the 
peculiar symptoms are so well marked that its nature is plainly manifest. 

Treatment. — The safest and surest plan of treating a person bitten by a rabid 
animal, Is immediate and total excision of the parts. Forcible suction is good ; 
also, ligature above and below the wound •will aid in preventing absorption. 
Next to excision, complete cauterization is the best thing. Apply caustic potass, 
freely, follow with vinegar as a wash, and poultice with : 

R— Pul. Lobelia 5 i. 

" Elm Si. 

Sulphite Soda S ii. 

Make a poultice and apply warm. This will lessen the danger and may 
effectually prevent the disease. A strong tea of Scutellaria, drank freely, and, in 
alternation, a teaspoonful of tincture lobelia. 

Remedial agents are few, but the best and main dependence of the Amer- 
ican practice is Scutellaria, agrimonia, lobelia, valerian and sulphite of soda. 
The sulphite of soda locally and internally, has the effect to antidote the poison 
and prevent its absorption. A saturated solution should be constantly applied' 
or with lobelia in form of poultice, with the administration of ten to twenty 
grains internally three times a day. Allopathy and homeopathy alike offer no 
cure for hydrophobia. Hydropathy is a farce when it comes to this disease, as 
no patient can possibly stand water. 

So, to the American practice, alone need we turn for hope in this terrible 
calamity. We must keep in mind we have a terrible poison to neutralize ; some- 
thing that diffuses itself all through the nervous system, and remedies must be 
given to suspend the action of the poison. Lobelia is a partial antidote, in fact, 
by some is considered a specific. It should be given freely, and repeated, dose 
after dose, until the patient is unable to move a limb. This is a powerful but 
safe remedy, and in connection with the following, I may claim a real specific 
for this most terrible poison : Give a strong tea of Scutellaria, or if you cannot 
get the herb, the fluid extract — half a teaspoonful in a cup of warm water every 
hour; give, also, at same interval, sixty drops fluid extract agrimonia in water. 

Electricity is good. Place the bedstead on glass, and apply the positive cur- 
rent to the spine and negative to the stomach. Let the patient inhale chloro- 
form, not to the full effect, but partial. Give twenty drops of fid. ext. sumbul 
every half hour until the pupil contracts. 

The great object in treatment after the symptoms begin to appear, is to sus- 
pend the nervous system till reflex action is prevented, and I am fully persuaded 



250 Principles and Practice of 

that the above treatment will keep the patient from the violent symptoms, 
which, if they fail to appear before the ninth day, are easily controlled thereafter. 
Convalescence is to be established on tonics, phosphorus, etc. 



ASPHYXIA. 



The characteristics are a sudden and total suspension of all mental and cor- 
poreal functions. 

Persons apparently drowned. — It is now a well established fact, that the 
principle of life may lie dormant in the body after it is apparently dead, and 
that it may be resuscitated and rescued from a premature grave by the 
means recommended by the various humane societies instituted in our country. 
As soon as the body of a person recently drowned is taken out of the water, it 
must be carefully conveyed with the head raised, to a house or other place 
where it can be laid dry and warm, avoiding the destructive method of 
hanging it by the heels, rolling it on a barrel, or laying it across a log on the 
belly. 

The clothes must be immediately stripped off and the body wrapped up in 
blankets well warmed. It should be laid on its back with the head a little raised- 
If the weather be cold, it should be placed near a fire and a heated warming 
pan should be passed over the body ; but in warm weather it will be sufficient 
to place it between two blankets well heated, or in the sunshine, taking care to 
prevent the room from being crowded with any persons who" are not necessarily 
employed about the body. At the same time the whole body should be rubbed 
with the hand, or hot woolen cloths. 

The rubbing should be moderate, but continued with industry, and particu- 
larly about the breast. The immediate application of frictions is of the utmost 
importance, as many have been recovered by friction only, when early used. 
When signs of returning life are apparent, the friction must be continued but 
more gently. 

These methods must be continued three or four hours, as in several instances 
they have proved successful, although no signs of life appeared until that time. 
When the patient is able to swallow, he must take some wine, brandy, or rum 
and water. The process of reanimating a lifeless body is the most interesting 
that the physican meets with. Decision, promptitude and energy must attend 
every step, not so much for the purpose of doing a great deed, as for the pur- 
pose of doing what is necessary with dispatch and correctness. 

NOXIOUS VAPORS. 

Suffocation and immediate death may be occasioned by entering wells, cel- 
lars, caverns or mines, that have long been kept closely confined from the at- 
mospheric air. The deleterious fumes arising from burning charcoal, or those 
from fermenting liquors, etc., may likewise produce the same fatal effects if im- 
prudently received by any person into the lungs. 

The external appearance of persons thus suffocated, is as follows : The head, 



American Medicine and Surgery. 251 

face, and neck are swollen ; the eyes are propelled from their sockets, the 
tongue is protruded from one side of the mouth ;.the jaws are firmly closed ; 
the face is of a livid, and the lips of a deep blue color ; the abdomen is inflated ; 
the body is insensible to pain, and the person appears to be in a profound sleep. 
Immediately on discovering a person apparently dead from such cause, the win- 
dows and doors ought to be thrown open, and the body be undressed and ex- 
posed freely to cool air, the face be sprinkled with vinegar, and cold water be 
thrown from buckets over the whole body for some time. If this method fail, 
friction and the other means recommended for the recovery of drowned persons 
should be put in practice. 

FATAL EFFECTS OF LIGHTNING. 

Persons injured by a flash of lightning, though apparently dead, may in many 
instances be restored by proper and timely applications. In general there are 
no external marks discoverable, though sometimes red streaks appear on differ- 
ent parts. The treatment to be pursued for the restoration of persons suffer- 
ing injury from lightning, is precisely the same as that for persons suffocated 
by noxious vapors. The sprinkling with vinegar, and the affusion of cold water 
are the principal means to be employed. In some instances of suspended ani- 
mation, electricity may be successfully directed. 

OF FROST-BITTEN OR THE EFFECTS OF INTENSE COLD. 

When persons are exposed to an intense degree of cold greater than the body 
is capable of sustaining, the vessels upon the surface, particularly the extremi- 
ties, are constricted by which the circulation is obstructed, an unusual quantity of 
blood is forced towards the brain and a fatal apoplexy is generally the con- 
sequence. The first alarming symptom is a drowsinesss, or almost irresistible 
propensity to sleep, and if this propensity be indulged, it will assuredly prove 
the sleep of death. 

Whenever, therefore, a person is long exposed to cold, it should be recollected 
that his safety greatly depends on the constant motion and activity of the body 
and firm resolution to resist the propensity to drowsiness. If unfortunately a 
person has suffered by exposure to extreme cold, so that every symptom of life 
has disappeared, the only proper method of treatment consists in placing the 
naked body in a cold room, or in a situation distant from the fire, and immedi- 
ately cover it, except the face, with a bed of snow, or plunge it into a bath of 
the coldest water for some time, and when taken out the whole body should be 
thoroughly rubbed with cloths wet with cold water. The immersion and the 
friction should be repeated and alternately applied for a length of time, for 
instances have occurred of persons being restored by a steady perseveraace in 
the process, when no signs of life had been discovered for several hours. 

When symptoms of animation appear, external warmth must be very grad- 
ually applied, and when the patient is able to swallow, a cup of tea or a little 
wine or brandy may be allowed. When the hands or feet have been exposed 
to severe cold and have become benumbed or frozen, the excitability of those 
parts will be so much stimulated that it they are brought near a fire, a violent 
inflammation, and probably a mortification will ensue. 



252 Principles and Practice of 

External heat should, on no account be applied, but the frozen parts ought to 
be immediately covered with snow, or immersed in cold water, until they re- 
cover their natural warmth and sensibility, and if necessary, the applications 
and the friction should be repeated and continued for several days, and after- 
wards the external warmth must be applied in a gradual manner. 

The application of goose grease, or the fat of the common fowl, has been 
successfully employed as a remedy to frozen limbs, even when the parts were 
perfectly black. The parts should be kept constantly covered with the grease. 
Tincture capsicum is excellent in frozen feet. 

LETHARGY, OR COMA. 

This is a species of apoplexy, which is manifested by an invincible drowsi- 
ness, or inclination to sleep, from which the patient is with difficulty awakened, 
and, if roused, he remains destitute both of sense and memory, and slumbers 
instantly again. The remedies applicable to this affection are the same as 
those advised in serious apoplexy, but especially counter-irritants, salt water 
baths, friction, etc., and cathartics frequently administered. 

SYNCOPE. 

This is a sudden swoon or fainting, in which the action of the heart is de- 
creased, and sometimes a total suspension of the pulse and respiration takes 
place. It is generally preceded by anxiety about the prascordia, a sense of full- 
ness ascending from the stomach towards the head, vertigo or confusion of 
ideas, dimness of sight, coldness of extremities, and paleness of countenance. 
In some instances the case is rendered more urgent by being attended with 
vomiting, convulsions, or an epileptic fit. When syncope occurs at the com- 
mencement of acute diseases it is generally considered unfavorable. 

This unpleasant affection may be produced by an excess or a deficiency of 
blood, a loaded or disordered stomach, violent pains, sudden emotions of the 
mind, profuse evacuations, particularly of blood, aneurisms of the heart, and 
other organic affections. 

During the fit the patient should be exposed to the open, cool air, and the 
neck and face sprinkled with cold water, and vinegar should be applied to the 
nostrils. 

The patient should be placed in a recumbent posture, and the extremities 
well rubbed with hot flannels, and soon as the power of swallowing returns a 
glass of wine or brandy and water, or some volatile spirits should be given. 

When persons are frequently affected with syncope, the peculiar cause should 
be ascertained, and the appropriate remedies applied. 

APHASIA. 

A loss of the cerebral faculty of speech, and the power of expressing thoughts 
by writing and gesticulation, is a discordance between the gray and white 
matter of the brain and spinal cord. At the same time we have loss of the 
memory of words, the memory of acts, and the memory of articulation. 
Aphasia is often transitory, as we have it, occasionally, during consciousness in 



American Medicine and Surgery. 253 

fevers, and it may be due partly to softening of the brain, hemorrhage of the 
cerebrum, apoplexy, etc. 

Symptoms. — Sudden deprivation of the power of speech, face holds its ex- 
pression of intelligence, movement of the lips and larynx healthy, a conscious- 
ness of what is wished to be expressed, with no power to express a word. 
Aphasia patients may have perfect knowledge. In cases, of aphasia, that have 
come under my observation, I have found most of them recover almost as 
sudden as they were attacked, 

Treatment. — Cases of loss of speech, not due to hemiplegia (paralysis) or 
chorea (St. Vitus dance) perfect recovery may be brought about by judicious 
means. We have, in all these cases, a jarring, or want of equilibrium, between 
the gray and white matter of the brain and medulla oblongata. The true 
theory is this : If the pupil be contracted, it denotes turgescence and congestion 
of the brain. In this class of cases nothing succeeds like small doses of lobe- 
lia, say fifteen drops of the tincture after each meal, with fifteen drops of 
fluid of extract xanthoxylum dissolved in sweetened water, half an hour before 
each meal. 

This will sometimes have to be continued for months before a cure is effected. 

There is usually a defective nutrition of brain and nerve tissues, hence the value 
of phosphorus, say twenty drops phos. acid dilute at night. When, however, 
there is dilation of the pupil then we give twenty drops of fluid extract of Scutella- 
ria, continue the phosphorus. The application of salt water baths to the spine 
and a wet towel to the nape of the neck will do good. At the same time the use 
of the syrup of hypophosphite comp. will have a happy effect in giving tone 
and strength to the system. If there is no organic difficulty, a cure will soon 
be effected. If due to lead or mercurial poisoning, then we must resort to 
powerful alteratives — something to antidote the poison and destroy it — using 
baths, etc. In aphasia from apoplexy the treatment must be directed to re- 
moval of the cause. These cases are the most hopeless, yet cures are some- 
times effected, and much good may be accomplished, even though we fail to 
cure. 



DISEASES OF THE EYE. 

As a part of the diseases of the brain, spinal marrow, nerves and the sensi- 
tive system, we bring in diseases of the eye most frequently met with and 
amenable to treatment of the intelligent general practitioner. A volume as 
large as this could be filled with description, cause, treatment, etc., of disease 
of the eye alone. Those who desire to make further investigation are advised 
to procure the latest work on diseases of the eye, but for the diseases of this 
organ, generally, we find very little demand for operations, caustic, or other 
severe local treatment. It is well to remember that in disease of the eye we 
have one of the most important organs involved, and one of the most sensitive 
of the sensitive system, and that due caution should be exercised in the treat- 
ment of this class of disease. 



254 Principles and Practice oj 



CONJUNCTIVITIS. 

This is an inflammation of the conjunctivia of the eye, or, in other words, 
the mucous membrane of the eye. Very common in a mild form, and is really 
the most common form of sore eyes. We have six varieties of inflammation 
of the eye: i, Symptomatic; 2, simple; 3, eruptive; 4, catarrhal ; 5, puru- 
lent ; 6, gonorrheal, and that peculiar to new-born infants. 

Inflammation of the eye may become chronic from neglect of acute cases. 

Symptoms. — These are well-marked in all forms of the disease. The con- 
junctiva is injected with red blood, and there is effusion of serum into the ave- 
ola between the conjunctiva and sclerotica called chemosis. There is extreme 
sensitiveness to light, a feeling as of sand, or dust in the eye, heat, swelling, stiff- 
ness of the lids, pain in the globe and edge of the lids ; the functions of the eye 
more or less perverted, intolerance of light becomes extreme, profuse, scalding 
tears, disordered vision, profuse secretions of the gland, severe pain on moving 
the lids, sense of distension and weight, rigidity of the organs, pain in the eye, 
temple and forehead. In cases long continued, the lid> become thick, swollen 
and turned outward, attended with entire loss of vision. We have various forms 
of this disease as before remarked, but in treatment they may all be classed the 
same, varying your remedies to suit the severity of the symptoms. Granular 
conjunctivitis is similar to the above, and is caused by little granules or bumps 
forming on the inside of the eyelid. 

Treatment. — In simple acute conjunctivitis, all that is required is to apply a 
poultice of slippery elm at night, or cloths saturated in cold water, locally a lo- 
tion made from the pith of sassafras will soothe and relieve inflammation, or: 

J^— Sulph. Morphia grs. ii. 

" Zinc grs iii. 

Aqua Camphor g i. 

Apply in the eye three or four times a day. When the disease has become 
chronic, we must resort to regular constitutional treatment. If the inflamma- 
tion runs high and "the patient is of full habit, give an emetic of lobelia comp., 
follow with a purgative and then put your patient on : 

J^t— Syr. Stillingia Comp 2 iv. 

Iodide Ferri 5 ii. 

Dose. — One teaspoonful before each meal. After meals twenty drops comp. 

tinct. serpentaria, applying the lotion of zinc and camphor given above. For 

granulated lids, nothing but a regular constitutional course will suffice : 

#— ,Comp. Syr. Frostwort O i. 

Iodide Potass Si. 

Dose. — One teaspoonful before each meal ; at the same time give : 

#— Fid. Ext. Corydalis "| aa. 

" " Alnus Rub J as. 

Dose. — Twenty drops in water after each meal. 



American Medicine and Surgery. 255 



PURULENT OPHTHALMIA. 

This is the worst of all forms of conjunctivitis. It is attended with all the 
symptoms of the simple varieties, with a profuse, purulent discharge, which is 
highly contagious, producing a like inflammation in others if it comes in con- 
tact. This purulent discharge appears within twenty-four to forty-eight hours 
after contact, and runs its course rapidly. To this class belong the purulent oph- 
thalmia of infants, and adults' gonorrhceal ophthalmia. Purulent ophthalmiain 
the infant is caused by contact of leucorrhceal discharge of the mother, or when 
the mother has gonorrhoea at time of birth ; neglect of cleanliness, or to remove 
the cheese-like secretion from the eyes of infants ; cold, damp, strong light, de- 
fective nutrition. Purulent ophthalmia in the adult is due to contagion, is pro- 
duced from contact, from impure air, cold, damp atmosphere, and general de- 
rangement of the nervous system, neglect of cleanliness. In damp seasons of 
the year, when we have a bright sun and rains alternately, we may have puru- 
lent ophthalmia. 

Treatment. — In the treatment of purulent ophthalmia, we should have an eye 
to cleanliness, keep the discharges well removed, and keep the eye saturated 
with a weak solution of sulphite of soda, say three grains to the ounce of 
water, and applied with a cloth ; locally the camphor zinc lotion, and at night 
keep a cloth saturated with sulphite of soda and lobelia, over the eye : 

J$— Sulph. Soda ) aa 

Tr Lobelia V 

Aqua j 5ii. 

Put the patient upon a thorough alterative course with d.iaphoretics, and lac- 
tuca or humulus to quiet the nerves and secure rest. Care should be observed 
to keep the eyes well cleansed or it may lead to ulceration and destroy the eye. 



GONORRHEAL OPHTHALMIA. 

This is produced from direct inoculation with the gonorrheal virus. 

Symptoms. — These are, a most severe, darting pain, and the inflammation 
runs high from the beginning. It is very dangerous, apt to result in ulceration 
or abscess, and destroys the sight and eyeball at once. 

Treatment. — This should be active constitutional and local, and the eye kept 
well cleansed and bathed with the sulphite of soda solution. Give patient ac- 
tive diaphoretics and diuretics. The following will act well : 

^fc— Fid. Ext Eupatorium Purp •. } aa. 

•' " Asclepias Tub j 3 ss. 



Dose. — Thirty drops once in three hours. 

| aa. 

j 3 xx. 



Jt— Sulph. of Quinine. 
Prussiate of Ferri. . . 



256 Principles and Practice of 

Make twenty powders and give one every two hours. At night give : 

P; — Fid. Ext. Lupulin . . ( aa. 

" " Lobelia ( 3 ss. 

Dose. — Twenty drops before retiring and repeat if rest is not obtained. 



SCROFULOUS OPHTHALMIA 

Is met with among children, and adults of a scrofulous diathesis. The char- 
acteristic feature of scrofulous inflammation of the eye is a spasmodic closing of 
the lids, intolerance of the light, the head turned to one side, with a disposition 
to burrow the face in the pillow. We often find one or more opaque spots or 
pimples on the cornea. The distinguishing symptom is the intolerance of light 
and the watering of the eye, with occasional sneezing. In addition we shall find 
the usual symptoms of scrofula. 

Treatment. — Will consist of hygienic measures, a good, nutritious diet, and a 
constitutional treatment, the same as directed under the head of scrofula ; locally, 
warm fomentations, the zinc lotion, or a lotion of : 

9;— Fid. Ext Myrica 2 ss. 

Aqua Camphor S iv. 

Apply to and in the eye, three or four times a day ; if this preparation causes 
pain reduce the strength by the addition of water. 



GRANULAR CONJUNCTIVA. 

This is often met with as a sequel of simple inflammation, and the use of 
lunar caustic, sugar of lead, blue stone (copper) and other similaragents. 

Symptoms. — We have a red fleshy appearance of the 1 conjunctivia with small 
elevations growing up from the same ; a generally puffy appearance of the eye. 

Treattnent.— This will consist of active alteratives. Comp. syr. stillinga and 
J odide potass, with serpentaria and asclepias to equalize the circulation. Locally 
we should apply : 

J^fc— Fid. Ext. Sanguinaria 5 ss. 

Aqua Distil. g i. 

Apply to the conjunctivia with a camel's hair pencil twice a day, in the interval 
using the zinc lotion. It is a good plan in all chronic inflammations of the eye, 
to put your patient on a thorough alterative course, and avoid as far as possible, 
irritants in or to the eye ; mild local applications — something to soothe and heal, 
not to burn and irritate. 

Every occulist with whom I am acquainted, relies upon nitrate of silver and 
atropia, as local application to the eyes and often neglects the general health. 
This is irrational, and must necessarily fail in a great majority of cases. 



American Medicine and Surgery. 257 



FOREIGN BODIES IN THE EYE. 

Foreign bodies may be mentioned as among the causes of inflammation of the 
coujunctiva, and in all cases they should be carefully searched for and removed, 
since so long as they continue in the eye will the inflammation be kept up. Not 
unfrequently will the disease continue for months, resisting every remedy, when 
a careful examination has detected some foreign body, which being removed, 
the complaint has been promptly relieved, As some difficulty* is often experi- 
enced in removing these bodies, the following observations on the subject may 
be interesting in this place : Foreign bodies entangled in the eye, occasion 
great pain, inflammation, and in inability to move the lids. They excite an ad- 
ditional secretion of tears, the flow of which frequently removes them. If this 
fails, the lids should be held open by the fingers, the patient desired to look to- 
wards the side opposite to that wherein the extraneous body lies, and the for- 
eign substance may be readily removed with a probe or a small role of fine 
linen. If one of the cilia? fall into the eye, it may be removed in the above 
manner. Small round bodies, such as beads, usually lie beneath the upper eye- 
lid, and are got out by laying hold of that eyelid by its ciliae and margin, draw- 
ing it outwards and then making the patient look down, or while the eyelid is 
held thus, a small curette is to be introduced under its temporal angle, and car- 
ried gently on toward the nose. If the bodies be very small, or consist of dirt 
or sand, they should be washed out by introducing the pipe of a small syringe 
beneath the eyelid at its outer angle, and then directing the stream of fluid, 
which should be tepid water, or milk and water, over the eye, towards the nose. 
Extraneous particles are sometimes insinuated under the upper lid, and adhere to 
it. In these cases, it is necessary to turn the inside of the lid outward, and this 
may be done without difficulty by the following means : The eyelashes should 
be taken hold of with the forefinger and thumb of the left hand, a slight pres- 
sure being at the same time made on the outside of the lid a little above the 
upper margin of the tarsi with the end of a probe (or some similar instrument) 
held in the right hand. The part being thus kept down by the instrument, the lid 
may be gently raised and then turned. In this everted position of the lid, the 
foreign particle is immediately brought into sight, and as before directed, may 
be removed with a probe or roll of fine linen, etc. When the particle is within 
the lower lid, this may be readily drawn down so as to bring the foreign sub- 
stance into view and it may be removed as above directed. 

Small bodies, such as particles of metal, the hard wings of insects, etc., are 
sometimes indented in the conjunctiva : a piece of fine silver wire, beat thin 
and fixed in a handle, will be found very convenient to remove them with. 
When splinters of metal get beneath the conjunctiva they should be seized 
with a pair of forceps and cut out with a pair of fine scissors. 

Workmen in filing or turning of iron, are liable to have particles from it fly 

into their eyes. These particles are often imbedded in the cornea. They should 

be removed with the point of a needle, or a common thumb lancet, which is to 

be introduced close to the body and the point then pressed outwards. If these 

17 



258 Principles and Practice of 

substances are allowed to remain suppuration will take place, and they will thus 
be separated and will drop out. 

But we should not trust to the operation of nature in these cases, for the con- 
tinuance of these foreign substances in the eye will generally produce violent 
inflammation and add greatly to the patient's suffering. Particles of canthari- 
des, pieces of mortar, and unslacked lime should be removed by means of a 
camel's hair pencil dipped in oil or glycerine. 



SCLEROTITIS, OR INFLAMMATION OF SCLEROTICA. 

Inflammation of the sclerotica may be said to be excited by various mechani- 
cal and chemical stimuli — such as blows, punctures, the lodgment of extrane. 
ous irritants on the surface or imbedded in the conjunctiva, and more especially 
when applied to the cornea ; acrid fumes, excessive application of the eye, or 
its exposure to great heat or reflected light, the irritation from a granular state 
of the palpebral conjunctiva, etc. 

Symptoms. — Inflammation of the sclerotica is very variable in its mode of at- 
tack, and irregular in its progress. Sometimes it comes on suddenly, is of a very 
violent character, and attains its height in a short time ; at others, it is of a more 
insidious nature, slow in its progress, involving the internal tissues in its disease 
and producing considerable mischief, while the practitioner is thrown off his 
guard by its indolent and shifting character. 

When it assumes an acute form, it usually attacks suddenly and commences 
with pain and redness of the eye, accompanied with some degree of pyrexia. 
The pain, as regards its violence, is exceedingly variable ; sometimes it is excru- 
ciating. We have been told by patients " if you do not afford us speedy relief, we 
shall go crazy ;" at others it is moderate ; occasionally it intermits, but generally 
it is unceasing, though undergoing exacerbations, which are usually most severe 
at night. The pain is generally seated in the eyeball, but extends itself also to 
the temple, the brow, the cheek bone, the teeth, or even the whole head ; some- 
times it is confined to one side of the head, occasionally there is severe pain in 
the ear or cavity of the nose; and it is often accompanied with rheumatic pains 
in other parts of the body. 

The sclerotica is more or less reddened, occasioned by the ramifications of 
minute vessels, which present a peculiar carmine or rose-red color. They are 
equally numerous on its posterior and anterior portion, and run in nearly straight 
lines to the very verge of the cornea. There is generally very profuse lach- 
rymation, though occasionally, especially at the commencement of the disease, 
the secretion of tears is suppressed. The pupil is often contracted, but preserves 
its circular form and thin flowing edge ; its color, especially that of its inner 
circle, is in this case rather lighter than natural ; this affection of the iris we be- 
lieve to be entirely sympathetic. There is often intolerance of light, but this 
symptom does not always occur, as is supposed by many writers. The tongue 
is frequently furred, and the gastric and biliary organs deranged. 

Diagnosis. — Inflammation of the scleiotica may be distinguished from iritis by 



American Medicine and Surgery. 259 

the following marks : The blood vessels are equally numerous over the whole 
sclerotica, while in iritis they are most numerous on its anterior part where they 
anastomose very frequently, and form a peculiar red zone. In the former dis- 
ease they advance to the very verge of the cornea, while in the latter they ter- 
minate abruptly about a line behind it, leaving a distinct pale circle, which is not 
seen in the former disease, or but rarely, and then it is not very evident. In 
the former, too, the redness will, on close examination, be found to be produced 
more by minute ramifications than by large trunks, as is the case in the latter. 
The iris, though contracted in the former disease, does not lose its circular form 
or its thin flowing edge, and become puckered and thickened as in the latter, 
nor does it exhibit any other change in its appearance, except becoming a little 
paler. When examined, the eye will be found more steady in the former, and 
will not roll incessantly as in the latter affection. Sclerotitis may be distin- 
guished from conjunctivitis by the absence of puriform discharge, and by the 
eyelids not being affected ; by the vessels being of a rose-red or carmine color, 
running in nearly straight lines, and being deep-seated ; while in the latter dis- 
ease they are darker, very tortuous and superficial. 

Treatment. — Give an emetic of lobelia comp. and follow with a purgative of 
podophyllin and leptandrin, then put your patient upon active diaphoretics, 
asclepias and serpentaria, in suitable dose every two hours, alternating with 
cypripedium, and lactuca to relieve pain locally, warm fomentations of hops, or 
poppy heads constantly applied, or if we can not obtain them, then a teaspoon- 
ful of fluid 'ixt. papaver to a half pint of boiling water. Clothes wet with this 
and changed frequently will give prompt relief. 

No irritating lotion or caustic should be used. After the acute symptoms are 
controlled, put your patient on a thorough alterative course, the syr. stillingia 
comp. with iodide potass, three times a day, diuretics, tonics and a good, nutri- 
tious but unstimulating diet. 

Treated in this way a favorable termination may be looked for. You will 
find in all inflammations of the eye a tendency to relapse, and you must direct 
the patient to avoid sudden changes of temperature, too much light, or alco- 
holic stimulants, for some time after the disease has subsided. 



INFLAMMATION OF THE CORNEA. 

Although the vessels of the cornea are not visible in the normal and perfectly 
transparent state of the texture, they become enlarged under inflammatory ex- 
citement, whether acute or chronic, and admit red blood, and they are suffi- 
ciently numerous to allow of the part becoming generally red under active or 
long-continued congestion. The various results of disturbed vascular action, 
such as union by adhesion, interstitial deposition, softening, thickening, indura- 
tio.i, ulceration, cicitrization, suppuration, mortification, occur in the cornea as 
rapidly and perfectly as in structures of which the vessels are larger and appa- 
rently more numerous. 

Symptoms. — In the more acute cases, the conjunctival vessels are distended, 



260 Principles and Practice of 

not, however, so as to conceal the changes which have occurred in the more 
deep-seated plexus, and the sclerotica generally has a rose or pink tint. A 
slight cloudiness of cornea may be produced and continue without visible in- 
crease of vascularity. Considerable pain and sense of tightness in the eye, and 
pain in the brow or forehead, often accompany the affection, especially in its 
early stage, in which we find white tongue, headache and general feverishness. 
There is increased sensibility to light, which is the more remarkable, as the 
changes in. the, cornea must diminish the quantity admitted into the eye ; it 
must be remembered that the sclerotica is involved in the inflammation, and 
that intolerance of light usually occurs when that membrane suffers. 

These symptoms are attended with lachrymation, especially on exposure to 
light. The inflammation may proceed with some rapidity and be attended with 
some feverishnesg. On the other hand, it is often of long duration, continuing 
for many months, and it does not proceed to suppuration. Often, after going 
through an acute stage, with pain and*feverishness, it assumes a more indolent 
character, and is protracted indefinitely ; the disease lasts, but the patient does 
not suffer. 

Causes. — Corneitis may be brought on by external agencies, by cold, damp, 
cr atmospherical vicissitudes. More commonly it owes its origin to internal 
causes, seeming to come on spontaneously. It is most frequent in the young, 
and seldom seen after the middle period of life. 

It occurs in those of unhealthy constitutions, especially the strumous, or 
where the general powers have been considerably reduced. 

The iris is generally involved, to a greater or less degree, in corneitis; it may 
suffer considerably if the inflammation be active, and allowed to proceed un- 
checked. 

Hence arise contraction of the pupil, effusion of lymph, and consequent per- 
manent adhesion of its margin to the crystalline capsule, and discoloration of 
the iris. 

Prognosis. — Under proper treatment, the interstitial effusion of the cornea is 
removed, the membrane regains its transparency, and vision is completely 
restored. The iris, however, exhibits after such recovery, a darker tint, with a 
little loss of brilliance, and thus the eye has a somewhat dull appearance. 

Under less favorable circumstances the cornea loses its transparency, and 
becomes changed in various degrees from leucoma to slight nebula. The iris 
is dull and dark colored, the pupil adherent, and there may be opacity in the 
opening. 

Treatment. — When fully satisfied we have inflammation of the cornea we 
should give an emeticof the comp. powder of lobelia, follow with a purgative 
of epsom salts, or seidlitz powders. Then put your patient on a regular altera- 
tive treatment. 

We shall find the syr. stillingia comp. or frostwort with iodide of potass, 
before meals, and asclepias and serpentaria one hour after meals act well. 
Under this treatment the inflammation will gradually subside, and the cornea 
assume its natural appearance, and no local treatment of a stimulating or 
astringent nature should be used. Keep the bowels regulated and direct a 



American Medicine and Surgery. 261 

generous, unstimulating diet. As the disease is formed and proceeds slowly 
the influence of treatment is gradual, and steady perseverance is necessary to 
insure success. 

When the treatment takes effect, and especially when the alterative acts deci- 
dedly, the vessels of the cornea contract, and the newly-deposited matter is ab- 
sorbed, the cornea regaining its transparency even where it had become gene- 
rally and rather densely opaque. It clears first in the circumference, the favor- 
able change gradually advancing towards the centre. 

When the constitution is naturally delicate, as it commonly is in those af- 
fected with corneitis, or where its powers have been reduced by disease and 
treatment, all depressing influences must be avoided as much as possible. 



PARTIAL INFLAMMATION OF THE CORNEA. 

Most frequently affects the entire cornea, especially in young persons. Some- 
times, however, about or after the time of puberty, the affection commences in 
one spot, other points become affected in succession, and thus disease may 
gradually extend over the whole. Pain has been felt in the eye, partial dullness 
is found at one point near the edge of the cornea ; a little redness is seen on 
the external surface of the eye, corresponding to the nebulas. On close inspec- 
tion, this redness proves to be seated in the sclerotica, and the conjunctiva is 
unaltered ; enlarged vessels are seen on the sclerotica, and we find minute ram- 
ifications extending from them on the cornea. Another patch of nebulse occurs, 
and ultimately the whole cornea, or the greater part of it, is affected. Local 
applications are not of much advantage. In the inflammatory period and when 
intolerance exists, fomentations are most comfortable to the patient. 

Stimuli and astringents are hurtful so long as active inflammation exists. 
When that is removed and the disease is beginning to yield, the papaver 
lotion may be tried. 



STRUMOUS INFLAMMATION OF THE CORNEA. 

Inflammation of the cornea frequently occurs in scrofulous persons. Its , 
local character and its real nature do not differ essentially from the description 
already given ; it can not therefore be regarded as a peculiar or distinct affec- 
tion. The entire cornea becomes dull and hazy, and then exhibits ,a more or 
less deep nebulous opacity, the surface having the sanded appearance already 
described. The conjunctival vessels are not much distended ; but there is a 
deep-seated, pink redness, from fulness of the trunks on the sclerotica, the 
minute straight branches of which form a zone round the cornea ; when the 
affection is very active minute twigs of the conjunctival vessels join the zone, 
which has a bright redness round the cornea. A dull, reddish-brown discolor- 
ation is seen in the cornea at its circumference, generally partial. This depends 
on an aggregation of minute vessels filled with blood, and ramifications are 



262 Pri?iciples and Practice of 

easily distinguished proceeding from the red zone to such discolorations. 
Lachrymation and intolerance of light are common to this affection with ordi- 
nary strumous ophthalmia, and it is not usually attended with pain in the eye or 
head. The constitution suffers ; the pulse being quick, the skin hot and dry, 
the tongue white, the appetite deficient and the bowels costive. The opacity of 
the cornea varies in degree. The pupil can be seen through it more or less 
clearly in some cases ; in others the iris and pupil are entirely concealed. Like 
other strumous affections this is obstinate and liable to relapse. 

The iris probably suffers with the cornea, though its condition is concealed 
by the changes going on in the latter membrane. 

Formidable as this affection appears, when fully developed it yields to Reform 
treatment and the normal condition of the inflamed textures is restored. It 
may, however, terminate in leucoma, contracted and adherent pupil, which may 
be closed more or less completely by an opaque, adventitious membrane, disor- 
ganization of the iris, and diminution or loss of sight. Under long continuance 
of the affection, which must be attended with increased secretion of the aqueous 
humor, the anterior chamber is enlarged, and the cornea may even be altered 
in figure. 

Treatment. — The treatment should be, first, an emetic, then a mild saline 
purgative, then administer the hypophosphite comp. before each meal. After 
meals : 



J$— Tr. Sanguinaria 

Fid. Ext. Iris Versicolor. 



J aa. 



" " Populus i 

" " Asclepias J 5 6S *' 

Dose. — Twenty drops in sugar and water. The moistened extract of bella- 
donna may be smeared on the brow to prevent contraction of the pupil and 
lessen irritability of the eye. Tepid fomentations are the most agreeable local 
applications ; a little fluid ext. papaver may be added to the liquid. Mild 
counter-irritation may be employed, if the disease does not yield to the means 
already specified. Under such circumstances a local stimulus may be tried, 
such as the vinum opii, or a two grain solution of the sulphate zinc and morphia. 



ULCERATION OF THE CORNEA. 

Ulcers of the cornea occur frequently in inflammation of the external tunics ; 
in the purulent and strumous ophthalmia. Ulcers of the cornea may be small 
or large, superficial and confined to the conjunctival layer, deeper and affecting 
the corneal texture, or even penetrating the anterior chamber, inflamed and 
spreading, stationary or healing. In the superficial ulcer there is a mere 
removal of the thin conjunctival layer, deeper and affecting the corneal texture, 
or even penetrating the anterior chamber. 

In the superficial ulcer there is a mere removal of the thin conjunctival layer, 
producing an appearance like that of excoriation in the integument. When 
the loss of substance extends more deeply, the excavation is more or less fun- 
nel shaped. The figure of the ulcer may be regular or irregular ; its surface 



American Medicine and Surgery. 263 

and edge smooth or unequal. The ulcerative process in the cornea, as in other 
textures, is an effect of inflammation, at least in the great majority of instances, 
to represent the latter, as produced by the irritation of the former, would be to 
invert the order of occurrences. The ulcer, however, being attended with ine- 
quality of surface, may be a source of irritation to the eye, in the movement 
of the globe and lids. We employ the same treatment that we should for an 
inflammation not attended with ulcer, and if ve succeed in arresting the in- 
flammatory disturbance, the ulcer will soon heal. 

No particular local treatment is required for this symptom. When the ulcer 
is healing we shall find it the best course to leave the case to its natural pro- 
cess, empJoving merely tepid ablution. The notion that ulcers of the cornea 
require the use of lunar caustic has prevailed generally, and led to injurious 
practice. In the inflamed and spreading state of the sore, such treatment would 
be most mischievous ; when the process of repair is going on properly it is, at 
least, unnecessary to resort to any local treatment. 

In obstinate cases of chronic ulceration, which, with little inflammation, will 
sometimes creep slowly over the cornea, healing on one side, while it advances 
on the other, I have found great benefit from counter-irritation in the temple. 



OPACITIES OF THE CORNEA. 

These are generally the result of disease being produced by inflammation. 
New matter is deposited during inflammation and becomes organized, thus 
causing the opaque change. Therefore, when we see opacity we infer that in- 
flammation has preceded ; and, generally speaking, the intensity of the opacity 
is in proportion to the violence of the preceding inflammation, as is exemplified 
in purulent ophthalmia, and in the acute corneitis, proceeding to suppuration 
This, however, is not necessarily the case, as certain inflammations of the cornea 
are characterized rather by the deposition of the new matter, than by the vascular 
congestion ; so that considerable general opacity may be produced without much 
external redness of the eye and a nebulous state of the membrane is sometimes 
seen without any other evidence of increased vascular activity. 

The term opacity is a general one, including all the changes which affect the 
transparency of the cornea, from a barely perceptible film, to whiteness like 
that of marble or chalk. Opacity in its slighter form is called nebula, haziness 
or dullness, there is a milky, cloudy, or smoky appearance of the part ; a state 
in which the transmission of light is only partially impeded. The more dense 
opacities extending through the laminae, are called leucoma or albugo. The 
term macuta is applied ,to small patches, or specks. The popular word for 
opacity is film. The color of the opaque part is different in different instances ; 
generally speaking, it is bluish-white like milk, or gray, it may be pearly or 
silvery, even marble ; there is sometimes a yellowish, and occasionally a reddish 
tint. 

Permanent enlargement of vessels is sometimes conjoined with opacity of the 



264 Principles and Practice of 

cornea, and we see one or more trunks containing red blood ramifying on the 
part. 

The effect of the morbid condition on vision will vary according to the den- 
sity and position of the opacity. The slightest film or cloud opposite the pupil 
will interfere with vision materially, while the most dense leucoma near the cir- 
cumference does not injure the sight. Dimness is sometimes caused by a central 
cloudiness, so faint that it can only be detected by close inspection of the organ 
in various positions. 

Treat7nent. — Our first object is to arrest inflammation, where that is still 
present. If we do this, and wait a little, the opacity will diminish of itself, the 
newly deposited matter, which has caused the opaque change, being absorbed, 
as inflammatory interstitial effusion is removed in other textures. In children 
the process of nutrition and absorption are vigorous; there is an active removal 
and deposition of materials, and the changes which the cornea undergoes are 
very striking ; although the membrane should be so opaque in a child as to 
render the iris invisible, it will completely recover its transparency. After re- 
ducing the inflammatior, and removing all irritation, after waiting to see what 
can be done by the natural process of absorption, we may adopt further meas- 
ures for lessening the opacity. The effect of counter-irritation with attention 
to diet, and to the state of the stomach and bowels, will often be very consider- 
able. The absorption of the newly deposited matter may be assisted, after 
these means have been put in force, by the employment of stimulants or astrin- 
gents ; the best of which is a solution of the sulphate of zinc and morphia. 
This may be either dropped into the eye, or applied to the opaque part by means 
of a camel's hair pencil. If this does not act well, try: 

fy— Fid. Ext. Myrlca 3 i. 

Tr. Sanguinaria gtts. x 

Aqua Camphor 3 iv. 

Apply with camel's hair pencil three times a day, and in addition, a general 
alterative and tonic treatment. 



IRITIS. 

Inflammation of the iris. This is the part we might term the middle portion 
of the structure of the eye as it lies between the cornea and crystaline lens. It 
divides the eye into what we term the anterior and posterior chambers, cavity 
containing the aqueous humor of the eye, these cavities are lined by a mem- 
brane similar to that covering the heart and bowels (pleura peritoneum). In- 
flammation there is of. an adhesive kind, and is usually the most formidable of 
all the inflammations of the eye. The effusion of lymph may stop the move- 
ment of the iris, change the form of the eye to all appearances, and may even 
close it up altogether. 

Symptoms. — The eye is red, vision dimmed, the light intolerable, pain in the 
eye and nerves around the eye. We may have deep-seated, tearing, lancinating 
pains in the eye and extending to the top of the head, spasmodic movement of 



American Medicine and Surgery. 265 

the globes of the eye, severe pain on moving the eye, specks or black spots float- 
ing before the eye, effusion of blood and matter into the anterior chamber of 
the eye, irritability of the whole system, gastric, febrile and other symptoms 
making their appearance. Gray or blue eyes change to a yellow tint, while 
black assume a red appearance ; there is throbbing pain in the eye, mental de- 
pression, etc. 

Causes.— The causes of this disease are various. It may come from sudden 
exposure of the eye to intense, glaring light, from surgical operations on the 
eye, often met with among engravers, watch makers, needle women, etc. May 
sometimes result from mechanical injuries, constitutional taints, rheumatism, 
scrofula, mercury, syphilis, etc. It causes more constitutional disturbance than 
any other inflammatory disease of the eye. 

Treatment.— -The treatment of iritis varies according to the cause. Our ef- 
forts should be to subdue inflammation, arrest effusion and create absorption of 
lymph, preserve the pupil and allay the pain. Our treatment must be active, as 
the tendency of the disease is to run its course rapidly. To meet the indications 
of the case, give : 

Tfr— Podophyllin . aa 

Leptandrin ) grs iv. 

Mix and make four powders. Give one in a teaspoonful of cream of tartar 
every night. Give every three hours : 

^fe— Fid. Ext. Serpentaria -\ aa 

" " Aletris Far 



" " Asclepias Tub. ... ' '.'.'..'..] 3 ss. 

Dose.— Thirty drops in water. Continue till the pulse is reduced. Counter- 
irritanis to the neck may do good, use equal parts oil capsicum and croton, apply 
to the nape of the neck, give three times a day the comp. syrup of yellow dock, 
with the iodide potass. 

Apply around the eye fluid ext. belladonna, so as to keep the pupils well dis- 
tended. After the acute symptoms have passed, we would get up a healthy 
tone to the system by giving cinchona, or the hypophosphites as a tonic. Daily 
bathing will be found excellent. A light, nutritious diet, avoid all alcoholic 
stimulants, or any thing that tends to excite the circulation unduly. 

The alterative treatment should be persevered with until all traces of inflam- 
mation have passed. 



AMAUROSIS. 



The imperfection or loss of sight which results from affection of the nervous 
apparatus belonging to the eye, whether that affection be seated in the retina, the 
optic nerve, or the sensorium, whether it be idiopathic or primary, sympathetic or 
secondary, whether it consist in vascular congestion, inflammation, or organic 
change, or simply in functional disturbance, is called amaurosis. 

This word means dim or darkened sight ; it is a general term embracing affec- 
tions of the nervous visual apparatus in all their forms or degrees. 



266 Principles and Practice of 

The expression, Gutta Serena, employed by the writers of the Middle Ages, 
is often used as synonymous with amaurosis ; it is more properly applied to that 
full developm-nt of the nervous affection in which complete blindness has been 
produced ; the patient can no longer discern objects, however large ; he can per- 
haps distinguish light from darkness, or he may be unable to make that distinc- 
tion. This term seems to have been derived from the pathological notions 
formerly prevalent respecting the cause of blindness. 

It was supposed to result from the effusion of a humor or fluid, at or behind 
the pupil, as the latter retained its natural blackness in amaurosis, the effused 
drop was said to be clear. 

Symptoms. — The leading symptoms of amaurosis consist in the variously 
altered state of the function. We find sight impaired in all possible ways. 
The most various imaginary objects and colors appear before the eyes. 
In different instances there are all kinds and degrees of defective perception 
in respect to the form color, and proportion of objects, and their relations 
to each other, augmented and diminished sensibility to light, impediments to 
vision most diversified in degree and kind. In the beginning of the affection 
patients complain of the sight being weak or dim ; the imaginary objects 
called muscas are seen; objects are perceived but imperfectly; they appear 
more or less obscured by cloud or haziness ; the letters of a book run into- 
each other and become confused ; the eye is soon tired, and waters or be- 
comes bloodshot if exertion is continued. Sometimes near objects are not 
clearly recognized, when those more distant are seen perfectly. This incipient 
stage, in which vision is partially impaired, is amblyopia, or weakness of sight; 
it is sometimes seen as a permanent condition. 

They who divide amaurosis into two kinds, that with increased and that 
with diminished sensibility of the retina, enumerate, as symptoms of the 
former, various kinds of impaired vision, some of which rather denote the 
period of excitement in disease of the retina, than the more advanced stage, 
ordinarily designated as amaurosis. Some of the symptoms now alluded to 
are merely the offspring of sympathetic disturbance caused by primary dis- 
order in other quarters. 

Causes. — The causes which contribute more directly to the occurrence of 
amaurosis, are analogous in their nature and operation to those which pro- 
duce disease in other textures of the eye and in other parts of the body. 
Excitement of the circulation by errors in diet, particularly by intemperance 
in drinking, and the determination of blood to the head more immediately pro- 
duced by such indulgences, are circumstances of frequent and powerful opera- 
tion in causing disorder and disease of the retina, as well as other parts of 
the eye, and of the brain. A sedentary mode of life, and residence in bad 
air, seriously aggravate the injurious effects of these disturbances. The con- 
tinuance of such habits through a course of years impairs the functions of 
the assimilative organs and nervous system, and thus induces an unhealthy state 
of constitution, in which amaurosis occurs more frequently than in the direct 
plethora caused by excess in an individual whose general powers are unbroken. 
It should be mentioned here that ansemia is almost as frequent a cause of amau- 



American Medicine and Surgery. 267 

rosis as plethora. We have seen this affection result from the anaemia produced 
by profuse flooding after delivery or miscarriage ; by too frequent child-bearing, 
protracted lactation, debilitating occupations, innutritious diet, defective hem- 
atosis, granular degeneration of the kidney, etc. 

In a great number of instances the immediate or exciting cause is exces- 
sive exertion of the organ, particularly its employment on minute or shining 
objects. 

Limited or temporary exposure to strong light may produce amaurosis 
suddenly, as in a stroke of lightning. 

Diagnosis. — The distinction betweem amaurosis and cataract will Be more 
fully considered in my description of- cataract. 

It may be mentioned here that the most certain means of distinguishing 
amaurosis from cataract is afforded by a catoptric examination. In perfectly 
uncomplicated amaurosis, the three images of a candle can always be seen, 
whilst in cataract the second upright, and the inverted images are one or both 
absent, or changed in size, brilliancy, or distinctness, as will be pointed out in the 
chapter on this disease. 

Prognosis. — Our prognosis of amaurosis is favorable when not due to local 
injury, congestion, or mechanical obstruction. In cases arising from cyst, 
tumors, etc., the amaurosis may disappear when cause is removed. 

Treatment. — This should be both local and constitutional. The first is to be 
done bv applying irritating plasters behind the ears or at the back of the neck, 
and continuing them for a considerable length of time, by promoting a dis- 
charge from the nose by means of : 

fy— Pulv. Sangumaria 1 aa. 

Pulv. Myrica v J 5 i. 

Mix. — Snuff up the nostrils several times a day. Electricity has been em- 
ployed in some cases with the happiest effects, when other remedies have failed, 
by passing very slight shocks through the forehead twice a day, and afterward 
drawing sparks from the parts surrounding the eye or eyes, which plan ought 
to be persevered in for a proper length of time. 

Stimulants have been applied immediately to the eyes in some cases of amau- 
rosis with a good effect, but more particularly in those which seem to depend 
upon an irritability of the optic nerve. 

In such cases an infusion of dried capsicum in water, in the proportion of 
one grain to the ounce, may be made use of, dropping a few drops into the 
eyes morning and evening. The severity of the pain may be great at first from 
this application, but by perseverance it will be found to abate. The vapor 
arising from warm, rectified spirits passed through a tube and received into the 
eyes, has sometimes produced a good effect. 

Constitutional treatment will depend upon the cause. Amaurosis is, after all 
that may be written or said of it, a species of paralysis, and may be due to op- 
posite causes, either too great fullness of blood to the brain and spinal cord, or 
lack of blood to the same. When due to the first— plethora— then we should 
put the patient upon: 



268 Principles and Practice of 



J^.— Syr. Stillingia Comp O i. 

Iodide Potass Si. 



Dose. — One teaspoonful three times a day, at same time : 

J£fc— Fid. Ext. Serpentaria 

" " Asclepias 

" " Scutellaria 



. 1 aa. 
, J 5 ii. 



Dose. — Thirty drops three times a day, with the irritating plaster at back of 
neck, warm foot baths, cold applications to the eyes. When we have a condi- 
tion of anasmia, lack of blood to brain and spinal marrow, then our treatment 
should be directed to correcting that trouble: 

Jfr— S*vr. Hypophosphite Comp O i. 

Tr. Nux Vomica Sss 

Mix — Shake well and give a teaspoonful three times a day, at night twenty 
drops fluid ext. Scutellaria to procure sleep. Keep the bowels well regulated, 
as in either form of amaurosis constipation aggravates all the trouble ; strict 
attention to hygiene, and a good, nutritious diet. Avoid alcoholic stimulants, 
the clothing should be warm and sufficient to protect from changes of the 
weather, etc. Under this treatment amaurosis, if not due to some local irrita- 
tion, will soon disappear. When it occurs in nursing women they should be 
directed to wean the child, and the general course pursued as in other anaemic 
condition of the blood. Amaurosis from nervous or sexual debility usually 
disappears when the cause is removed. 



CATARACT. 



This term should be limited to opacity of the crystalline lens or its capsule, 
whereby the rays of light are, in a proportionate degree, intercepted on the way 
to the retina, and vision is thus impaired or reduced to a mere perception of 
light and shade. 

Before examii.ing any patient with suspected cataract, the pupil should be 
dilated with atropia, and then, if there be cataract, there will be seen an opaque 
body of a gray, bluish-white or amber color behind the pupil ; objects appear 
•as if surrounded with a mist or as if a cloud was interposed between them and 
the eye ; and that sight is better in the evening, or when the back is turned to 
the light, or after the application of atropia — obviously because the pupil, being 
dilated under those circumstances, permits more light to pass through that part 
of the lens which is yet transparent. 

Besides these evidences of cataract, we have, the catoptric test, that is, the 
mode of examination of the eye by the reflection of light. 

When a lighted taper is moved before the eye of a healthy person, three 
images of it may be observed : 

i. An erect image that moves upward when the candle is moved upwards, 
and that is produced by reflection from the surface of the cornea. 

2. Another erect image, produced by reflection from the anterior surface of 
the crystalline lens, which also moves upward when the candle is moved up- 
wards. 



American Medicine and Surgery. 269 

3. A very small inverted image that is reflected from the posterior surface of 
the crystalline lens, and that moves downward when the candle is raised up- 
wards. 

In cataract this inverted image is from the first rendered indistinct, and soon 
abolished, and the deep, erect one is soon abolished also. 

Causes. — Cataract is sometimes attributable to inflammation, and may be 
caused by wounds or other injuries of the lens. Impaired nutrition, heredi- 
tary predisposition, is an exceedingly common cause ; it is also an accompani- 
ment of some diseases, as'diabetes. 

There is no known treatment, either local or constitutional, that will cure 
cataract. 

Nothing short of operation will benefit it. 



ENTROPIUM. 



This is an inversion of the eyelids, and is caused by the contraction of the 
margin. It is usually the result of conjunctivitis, or inflammation of the eye. If 
it exists for any length of time it causes considerable trouble, from the irrita- 
tion of the edges rubbing against the eyeball. 

Treatment. — Sometimes there is great relaxation of the lid ; then we must 
gently bring it to its natural position, and apply a coating of collodion on the 
lid. or we may attach a piece of adhesive plaster to the lid, draw it down and 
fasten on the cheek. Should this not succeed, a solution of tannic acid applied 
over the lid, as directed for the collodion, is best. At the same time remove any 
local inflammation by the application of remedies mentioned under the head of 
Conjunctivitis. 



ECTROPIUM. 



This is an eversion of the eyelids — ^that is, a drawing away of the lids from 
the eyeballs, the conjunctivial surface turned outward, and the edge or lashes, 
displaced, sometimes caused by a scar from a burn or other injury to the lids., 
and sometimes as a result of paralysis. In ectropium, the eyeball, being de- 
prived of its natural protection, is exposed to constant irritation, and a state of 
chronic inflammation of the conjunctivia results, weakening the eye, and liable 
to run into ulceration, and may destroy the lachrymal duct. Then the tears 
pass over the cheek. 

Treatment. — In recent cases, this is simple, and consists in applying : 

^-Collodion u. Si 

Tannic Acid grs. iii. 

Mix, and apply to the lid with a camels hair pencil. 

This is the only effectual remedy in ectropium. We may use such local ap- 
plication as are best calculated to subdue inflammation. Sometimes an opera- 
tion is necessary. 



270 Principles and Practice of 



PTERYGIUM. 

In the affection thus designated, a portion of the conjunctiva, or triangular 
figure, belonging partly to the corneal division of the membrane, becomes 
thickened or otherwise altered with enlargement of its vessels, and increased 
redness. The basis and the larger part of the pterygium lie upon the sclerotica, 
the basis being towards the circumference of the globe ; the narrow portion is 
situated upon the cornea, on which the apex gradually advances. 

Symptoms. — Pterygium comes on quite insensibly, and grows very slowly. 
The patient experiences no great uneasiness, and is not aware that the disease 
exists till it has made some progress. Its slow increase is a distinguishing char- 
acter of the affection ; it will exist for many years without making much ad- 
vance. Yet it gradually proceeds towards the centre of the cornea, and the 
advance of the opaque body in this direction naturally txcites apprehension 
that it may ultimately interfere with vision, especially if there should be one on 
each side of the eye. I have known some instances in which it has been ap- 
parently stationary for a very long time, so that at the end of from ten to twen- 
ty years it has not enlarged so as to affect sight. 

Diagnosis — The insensible origin, the very slow growth, the triangular figure, 
the peculiar vascular and fibrous change of the membrane, its loose connection 
with the surface of the globe, and the absence of previous or concomitant in- 
flammation or uneasiness, sufficiently distinguish true pterygium from the 
thickening, swelling and increased vascularity of the cornea dependent on in- 
flammation. If the term pterygium be confined to a change of texture thus 
characterized, it will not, I think, be seen before the middle period of life. 

Treatment. — So long as the disease remains in the quiet, stationary condition 
I have described, neither interfering nor seeming likely to interfere with vision, it 
should be left alone. I have succeeded in removing several by the direct appli- 
cation of a strong solution of sulphate of zinc. This I prepare by adding a 
scruple of sulphate of zinc to one ounce of distilled -water, and apply to the 
growth with a camel's hair pencil. This may be applied three times a day. If 
inflammation arises we should treat as in simple conjunctivitis. If carefully ap- 
plied and properly limited no inconvenience will follow its use. In a short while 
the membrane substance will gradually recede and disappear altogether in one 
to two months. 



MUSC/E VOLITANTES. 

This is little specks floating before the eyes, black spots flying over the field 
of vision, are produced by movable floating bodies near the retina. Always due 
to debility, those specks are nothing more than effusion. The removal of the 
debility, the fresh air of the country, tonics, attention, etc., are all that is neces- 
sary. Specks or spots on the eyes are frequently the consequence of inflamma- 
tion. These may sometimes be removed by the application of myrica, or the 



American Medicine and Surgery. 271 

sulphate of zinc lotion. When these means fail, the only remaining expedient is 
a surgical operation, which if judiciously performed, will sometimes succeed. 

A blood-shot in consequence of external violence, or straining by vomiting or 
coughing, seldom requires any thing more than to be fomented with warm milk 
and water, or a solution of sulphate of zinc. 

A watery or weeping eye, proceeding from a relaxation of the glandu^r parts 
of that organ, requires some astringent application, as ten drops of myrica in 
one ounce of water, apply in the eye three times a day. 

Fistula lachrymalis is a disease arising frnm an obstruction in the nasal duct 
preventing the tears and mucus from descending into the nose. A tumor is 
thus produced in the inner corner of the eye, and the tears and mucus run off 
down the cheek. 

A cure for this troublesome complaint may be attempted by the frequent ap- 
plication of the extract of phytolacca decandra. 

Strabismus or squinting, may proceed either from a nervous affection or a 
vicious habit acquired in children by having their eyes unequally exposed to the 
light, or by imitation from a squinting nurse or other example. When this de- 
fect has not b;en confirmed by long habi", it may be obviated by darkening the 
more perfect eye for some hours daily, by which means it will be gradually 
weakened, and the defective eye will be gradually corrected by using it. or the 
child may wear a mask which will inly permit him to see in a straight direc- 
tion. That condition of the eyes called myopia or short sightedness, may be 
in some measure remedied by the help of concave glasses, and in a contrary 
condition of the eyes, convex glasses will be requisite and useful. 

When the sight is considerably impaired and weakened by too constant ap- 
plication, especially night-watching and candle-light lucubrations, these causes 
should be immediately abandoned, and the use of green glasses will greatly as- 
sist in mitigating the complaint. When the great importance of the organs of 
vision and their very complicated and delicate structure are duly considered, it 
will appear obvious that too much care cannot be taken for their preservation. 
On the least appearance of diseased eyes, excess of every kind should be care- 
fully avoided, as the use of strong liquors or long abstinence from food, sudden 
transitions from darkness or obscure light into that of the bright light of sun- 
shine, or the glare of candles. All irritating causes, as smoke, the vapors of 
stimulating or volatile substances, vivid lights and glaring colors, are to be con- 
sidered as highly prejudicial to the organs of vision. Among the preventive 
means to be employed by those who are subject to disorders of the eyes, irritat- 
ing plasters on nape of the neck, food of easy digestion, and occasional laxa- 
tives, are to be regarded as of no inconsiderable importance. 

Various other diseases and derangements of the organs of vision are met 
with, they usually require skillful operation and manipulations to remove or over- 
come them, and the reader is referred to works on the eye for a full elucidation 
of the more obscure diseases of this important part of the sensitive system. 



272 Principles and Practice of 



DISEASES OF THE EAR. 

In its pathology the ear does not differ from other structures. From this 
general conclusion, perhaps may be excepted inspissation of wax in the meatus, 
the exanalogue of that secretion not being elsewhere met with. Inflammation, 
therefore, is the affection to which, for the most part, this organ is obnoxious, 
and as this disease is modified in its progress, in its symptoms, and in its effects 
by the structures which it atticks — by the local predisposition of the organ af- 
fected, by the general constitution of the individual, by the causes which may 
excite it, by the external circumstances or conditions which accompany it — so 
have the affections of the ear been arranged under various heads, nearly all of 
which may be reduced to inflammation and its consequences. As in all other 
organs, of which the seat of function is in an expanded nerve, the ear is like- 
wise subject to an anaesthetic affection dependent on some hidden morbid con- 
dition and occasionally on inflammation either of the acoustic nerve or of thore 
parts of the brain in connection with the organ. Again, in consequence of the 
vicinity of the ear to the brain, it often participates in the diseases and accidents 
of that organ ; and the reverse is frequently observed of disease extending from 
the ear to the brain, or the skull. 

Lastly of the accidental introduction of foreign bodies into the meatus ; the 
rupture by a blow, or otherwise of the membrana tympani, have been esteem- 
ed peculiar to the ear ; but perhaps hardly with justice, as nearly similar acci- 
dents are met with in the nasal and visual organs. Only such diseases of the 
ear as are frequently met with in a general practice will be treated of in this 
work. The reader is referred to the latest works on the ear for a more exten- 
sive description of diseases of this important part of the sensitive system. 



OTITIS. 



Acute Otitis, Otalgia or Earache, does not frequently attack the entire organ 
at the same time, nor from the same cause ; but generally commencing in either 
the external ear, or the tympanum, it extends to the rest of the apparatus ; thus, 
if the cause be applied, as often is the case, to the auricle or the meatus, the in- 
flammation in its progress may reach the membrane and the cavity of the tym- 
panum, and pass on to its appendages, and even to the labyrinth. If, on the 
other hand, the inflammation be excited in the tympanum, immediately or 
through the medium of the eustachian tube, it may spread inward to the iaby- 
rinth and outward to the meatus. 

This circumstance evidently arises from the different degrees of exposure to 
the exciting causes to which the outer and inner divisions of the ear are liable; 
but it is very possible that the same sudden variation of the temperature may 
inflame at the same time the extended meatus, and the lining membrane of 
the tympanum, and thus that general otitis shall arise, but this is compara- 
tively an unusual occurrence. 



American Medicine and Surgery. 273 

Causes. — The causes of otitis are similar to those producing inflammation in 
other organs, modified in their frequency by the predispositions of the struc- 
tures. Among the most common may be enumerated cold, and especially ap- 
plied to the ear, when its temperature is unnaturally raised ; this exciting cause 
directly affects the auricle, and particularly the meatus, and indirectly the tym- 
panum, through the eustachian tube — a foreign body irritating the auditory 
canal, and wax inspissated to extreme hardness may be considered as a foreign 
irritant, wounds of various kinds, sometimes lacerating or cutting the mem- 
brane, the extension of inflammation from the surrounding parts, particularly 
of erysipelas from the scalp, of scarlatina, of variola, of rubeola, etc., to the 
outer ear ; of tonsilitis, or syphilis, or any affection of the fauces to the eustachian 
tube, and outward to the tympanum — of disease of the brain, or its membranes 
to the labyrinth — likewise irritating injections administered to the auditory 
canal. 

Galvanism and electricity have been enumerated as exciting causes, when too 
freely used for the removal of deafness. Inflammation is described, also, to 
have arisen from metastasis in consequence of the sudden removal of cphthalmia, 
or of gonorrhce ; likewise to have been excited by a carious tooth. Otitis oc- 
casionally arises during the progress, or towards the termination of general 
acute disease, as continued or typhoid fevers. 

The disease is occasionally seen to pass to the ear from the neighboring parts, 
and back again, forming an alternating vicarious affection ; it also alternates in 
children with cutaneous eruptions, and especially during dentition. Individuals 
of scrofulous diathesis, of the syphilitic taint or having irritable mucous mem- 
branes, and those who are the subjects of cutaneous eruptions, are particularly 
predisposed to otitis ; but this predisposition is most remarkable in strumous 
children. 

The symptoms and consequences of otitis vary according to the structure of 
the parts inflamed, and as these variations are very great, authors are obliged, 
for the sake of perspicuity, to describe separately the diseases as they are 
locally situated ; and hence the division of inflammation of the ear into external 
and internal, is not only justifiable but very useful. 

Symptoms. — Acute inflammation may commence simultaneously in the auricle 
and meatus, the same cause affecting both parts at the same time, or it may be 
confined to either portion ; but more frequently it extends from the one to the 
other, and generally from the auricle to the canal ; yet the limitation of the dis- 
ease to the meatus is a very common occurrence. Any cause of inflammation 
being applied will excite the auricle into disease ; but it is more frequently af- 
fected with erysipelas, than with any other form of acute disorder. This part 
is peculiarized by the great readiness with which it becomes tumified, and in 
erysipelas by the large size of the vesications which are formed upon it ; which 
circumstances are consequent upon the perfect organization of the skin and sub- 
cutaneous cellular tissue. 

In the first instance there is rather sense of heat than actual pain ; but after- 
wards there is a burning and painful sensation, which soon becomes almost in- 
tolerable ; of course, the redness is excessive, the skin being naturally so very 
18 



274 Principles and Practice of 

well supplied with blood. From these circumstances it arises that one of the 
most distressing concomitants of erysipelas is the impossibility of the patient 
changing his posture from his back to lie upon his side, in consequence of the 
unbearable pressure upon the ear. 

The tumifaction of the concha is often so great as to completely close the 
opening of the meatus, by which nearly complete deafness is occasioned, even 
when the inflammation does not, as it generally does, extend into the canal. 

The disease often leaves the part thickened and hardened, by adhesive matter 
effused into the cellular membrane, or sometimes by a positive deposition in 
the fibro- cartilage. 

In the majority of cases the auricle is restored in time to its normal condition 
by the process of absorption, but occasionally the part continues ever afterwards 
indurated. An abscess is sometimes produced, which endangers an ulceration 
of the cartilage, and occasionally ulceration, to which the structure of the auri- 
cle is predisposed, even takes place without the formation of matter ; an open- 
ing is thus sometimes formed through the cartilage, which is exceedingly likely 
to become permanent. 

Sloughing of the cartilage is also now and then the termination of its inflam- 
mation ; this effect is most common when the ear has been frost-bitten, under 
which circumstance, the vital powers have been much reduced by the extreme 
cold, and are, therefore, incapable of bearing the consequent violent reaction. 

The auricle is also the subject of erythema, of small pox, of measles, in short, 
of all the inflammatory actions, either common or peculiar, which affect the cu- 
taneous system. These different diseases pass through their ordinary stages 
and produce their usual effects, with modifications arising from the predisposi- 
tion occasioned by the structure alluded to. The treatment must be conducted 
upon general principles ; when the inflammation is high, the object of the treat- 
ment will be so far to lessen its severity, during the necessary progress, as to 
diminish the probability of the affection extending to the meatus ; this desirable 
object, however, is often not to be obtained, and in many cases the patient 
must feel grateful if the spreading of the disease has been confined to the canal. 

With the above view we should resort to stimulating emetics as the comp. 
powder of lobelia, with warm fomentations to the ear. 

In the erysipelas variety the application of belladonna and glycerine will be 
found effectual. 

One of our best remedies is : 

J£fc— Tt. Belladonna 5 1. 

Pure Glycerine 5 ii. 

Apply to the inflamed surface with a camel's hair pencil, once in three hours. 
Constitutional treatment should be active, and directed to the removal of local 
irritation. 

#— Podophyllin gr. iv. 

Sugar of Milk gr. viii. 

Make four powders and give one at night. 



American Medicine and Surgery. 275 



INFLAMMATION OF TYMPANUM. 

When existing, unconnected with disease of the tympanal cavity, may rather 
be considered as belonging to external than internal otitis. 

Symptoms. — When inflammation occurs in the tympanic membrane exclusive- 
ly, the patient suddenly feels an acute pain at the bottom of the meatus, follow- 
ing the application of some irritant, which is generally cold wind striking sharply 
against the membrane, or the introduction of some foreign body, or perhaps a 
mechanical injury resulting from the removal of hardened wax or a foreign sub- 
stance ; or it may possibly be occasioned by too great a degree of vibration in 
consequence of unusual strength in the sround applied. The pain is accom- 
panied by buzzings as though something were fluttering in the ear, and by a 
lessened capability of hearing, and it is increased by loud sounds, by variations 
of temperature, and by pressure upon the ear. It becomes now and then unu- 
sually severe, which will continue for a few minutes, or sometimes much longer. 
When the membrana tympani is examined, with the assistance of a speculum 
and good light, it is found in mild cases, to be slightly reddened, and vessels 
may sometimes be distinguished upon its surface. In severe cases the mem- 
brane will present a universal blush, and blood vessels will readily be seen ; it 
will be thickened and swollen, and the attachment of the handle of the mallens 
be imperceptible. 

The milder degrees of inflammation, which may be termed sub-acu;e, rarely 
exist in general symptoms, and in the course of a few days the disease will . 
subside. In the severe cases the local symptoms will be aggravated, with dimi- 
nution of the cerumenous secretions of the meatus, which canal otherwise 
retains its natural appearance, and fever will be produced. 

The consequence of a high degree of inflammation of the membrane, or when 
the affection has been long continued, may be anticipated. The disease may 
extend to the meatus, or inwards to the tympanal cavity ; the membrane may 
become thickened by the adhesive inflammation, either throughout its whole 
surface, or in several spots, presenting a rugged appearance, and which being 
vascular, may resemble indurated granulations ; a fungus growth may arise, 
which is, however, much more frequently produced by the chronic disease ; lit- 
tle scales often exfoliate from the surface ; the affection may terminate in ulce- 
ration, injuring to a greater or less extent the cavity of the tympanum ; lastly, . 
chronic disease may supervene. It would appear from this history that the 
disease is first seated in the external cuticular membrane, and in its progress, or 
severe form, extends to the fibrous tissue. This is the form and seat of inflam- 
mation, which has frequently been described as otalgia or earache, which term' 
we have seen has been applied to all acute diseases of this organ. The sudden > 
accession of the pain, and its frequent subsidence without medicinal aid, with 
the difficulty in many instances of obtaining a good view of the state of the mem- 
brane, may afford an excuse for the surgeon considering it purely neuralgic. 
It very probably, however, takes somewhat of a neuralgic character, as in the: 
milder cases the vascular excitement does not appear to correspond to the; 



276 Principles and Practice of 

amount of pain and of general sensibility of the organ, and the nervous connec- 
tions of the membrane will favor such suspicion. 

Treatment. — In the treatment it is of much importance not to mistake the 
inflammatory character of the disease, as the introduction of opium and nar- 
cotics, which will benefit pure neuralgia, will here increase the excitement. In 
slight cases, the application of warmth and moisture over that side of the head, 
the maintenance of an equal temperature, the action of a purgative — and if 
there be no fever denoting increased action give a dose of lactuca, or papaver 
at bed-time. The more severe cases will demand the sameijne of treatment as 
directed in inflammation of external ear, to obviate the unfortunate conse- 
quences which may otherwise ensue. 

If the acute disease should continue, notwithstanding the treatment admin- 
istered, by which ulceration or induration, and thickening are threatened, the 
timely and judicious use of an alterative may be attended by the same happy 
results which are so conspicuous upon its administration in iritis. 



OTITIS INTERNA. 

This term evidently should include inflammation of the labyrinth ; but as the 
immediate effects of acute disease in this intricate structure are not recogniza- 
ble, and as they are only suspected in consequence of the derangement pro- 
duced, it has generally been confined to inflammation of the tympanum, where 
the disease may be early detected by attentive discrimination, and where its 
effects become apparent to every observer. It should therefore rather be called 
otitis media, or inflammation of the middle ear. 

The inflammation generally commences in the mucous membrane, and may 
or may not extend to the structures beneath, or it begins simultaneously in 
both, and in its course may reach and destroy the periosteum and bone. 

It may be divided into three stages : 

1. A simple puriform discharge. 

2. A puriform discharge complicated with fungi and polypi. 

3. A puriform discharge with caries cf the tympanum. 

Symptoms. — The symptoms of the severe affection, to a certain extent, resem- 
ble those of otitis externa, differing in consequence of the structure affected, 
of their greater severity, and of the circumstance of the matter when formed 
not meeting with a ready outlet. The symptoms are at one time ushered in by 
a severe pain in the ear, which is often neglected, and regarded as being what is 
commonly termed earache, and which may continue only for a few hours, or 
it may persist with occasional exacerbations, for two or three days, when it 
more or less suddenly extends to the whole of that side of the head. In other 
cases the symptoms commence with intense headache or insupportable hemi- 
crania ; the febrile excitement is most severe, the eyes are injected, watery and 
intolerant of light, the countenance is flushed and anxious, the skin hot and 
dry, the pulse frequent and hard, the secretions are suspended, the pain becomes 
excessive and extends through the whole head, but is most severe on the side 



American Medicine and Surgery. 277 

affected, and the patient particularly refers, as the most painful part, to the 
bottom of the auditory canal. 

The severity of the symptoms frequently abates in the morning, a reaction, 
often accompanied by rigors, coming on in the evening. The patient is also 
deaf on the affected side. 

Causes. — The causes of internal otitis resemble those of the external disease* 
the most common is undoubtedly cold, applied through the Eustachian tube, or 
perhaps through the membrane, or generally to the side of the head, the exten- 
sion of inflammation from the tonsils or the fauces, from the external ear 
through the membrane, or from the membrane itself ; but by far the most fre- 
quent cause is a cold wind blowing along the meatus, in a predisposed subject, 
in which event the meatus is defended by its secretion from the effects of the 
direct application of the same draught of cold air which indirectly affects the 
tympanum to serious disease. Scrofula is the great predisposing cause of 
internal otitis, which is not commonly met with in individuals who have not 
this peculiar delicacy of constitution, except ng when excited by accidental 
causes. In like manner syphilis, and all debilitating diatheses, predispose to 
this affection. 

Diagnosis. — So far the symptoms, though indeed acute, are insufficient to 
distinguish inflammation of the tympanum, from the most severe form of ex- 
ternal otitis ; to perfect the diagnosis, it is necessary to ascertain that the audi- 
tory canal is free from disease, and to take into consideration the longer inter- 
val of time between the first accession of pain and appearance of discharge. 
In external otitis the muco-purulent secretion occurs in a few days, or even a 
few hours ; in the internal disease a week or more will elapse before any pus 
is discovered, and then it escapes suddenly through a rupture of the membrana 
tympani, through the Eustachian tube, or through the ulcerated mastoid cells ; 
whereas in th2 external disease it is preceded by a serous moisture. 

This may be considered as the first stage of the disease, and is that of in- 
flammation, terminating in suppuration. 

It sometimes happens that timely treatment in a good constitution so lessens 
the inflammation that it terminates in a mucous secretion, or in resolution ; but 
in the great majority of instances it passes on to suppuration, and the escape 
of the pus may constitute the second stage. The distressing symptoms are 
relieved when suppuration is completed, in consequence of the pus being still 
retained in the tympanal cavity ; no certain data therefore exist, by which it can 
be known that the secretion has taken place, until it makes its exit, which may 
happen in a week, or it may not occur until after two or three weeks. 

Treatment. — In the severe form, whether primary or consecutive, our treat- 
ment must be directed to the removal of constitutional and local irritation. 

To this end we would give an emetic of lobelia comp. and follow with a vapor 
bath, giving at intervals: 

Ijfc -Fid. Ext. Asclepias ) aa. 

" " Cypripedium 

Dose. — Thirty drops once in two hours. 



) aa. 
fsi. 



278 Principles and Practice of 

Give an active cathartic at night, and if the symptoms continue we should 
give an active alterative. 

I=fc— Fid Ext. Iris Versicol 1 

" " AlnusRub '^ 

" " Rhus Glabra \ % . 

" " Helianthemum j 3 1. 

Alcohol 3 ii. 

Syrup Simplex S x. 

Dose. — One teaspoonful once in three hours until you have a manifestation of 
its effects. The local treatment will consist in capsicum plaster to the nape of 
the neck and the application of warmth and moisture to the side of the head, 
and in the careful avoidance of irritating the meatus by injections or otherwise. 
A hop poultice is good when we have much pain and throbbing. 

When the brain, unfortunately becomes implicated, then the head must be 
shaved, and evaporating lotions freely applied, either warm or cold, as may be 
the more soothing to the patient's feelings. 

This treatment should be kept up until we have a termination of the in- 
flammation. 



OTALGIA. 



Otalgia, or ear ache is caused by irritation of the auditory nerve, and though 
usually considered slight, or of little importance, it should have prompt atten- 
tion, as deafness may, and often does, result from neglected irritation. If the 
earache is due to neuralgia, then we must adopt the treatment directed under 
that head, but in ordinary cases give : 

9;— Fid. Ext Lactuca i aa , 

" " Humulus \ 5 i. 

Dose. — Twenty drops in water every half hour, and apply in the ear : 

P;— Tr. Aconite Fol -) aa . 

" Belladonna .. . (- — 

" Glycerine '....'..".'.'.'.v.'.".'.'.'.".'.'.'.'.'.'.'. j 3 ss. 

Mix. — One to three drops in the ear, and apply in the ear cotton to protect it 
from the cold. 



OTORRHCEA. 



Inflammation and ulceration of the ear is attended with a muco-purulent dis- 
charge from the ear. We meet with it in all classes, but mainly in young chil- 
dren during teething, when we have great irritation reflected to the auditory 
nerves. 

We have inflammation which, if neglected, finally runs into ulceration, or 
effusion, and then under ordinary treatment we have a permanent discharge 
from the ear. Few, very few, practitioners succeed in curing otorrhcea from 
the fact that they look upon it as a local disease, and treat it on that principle, 
and yet we seldom find it existing in a patient not of a scrofulous diathesis. 

Keeping this fact in view, our treatment will always prove a success. We 



American Medicine and Surgery. 279 

must remove all local irritation, as near as possible, then we must improve the 

general health by a nutritious diet, animal food, milk, white of eggs, etc., etc. 

Salt water baths daily, or tri-weekly, are of the utmost importance. Internally, 

we have nothing better than the syrup of hypophosphites, comp. It meets 

the indications nearer lhan any thing I have ever tried. Locally I have usually 

succeeded in arresting the discharge with the following : 

fy— Fid. Ext Hamamclis 1 aa. 

" Myrica Cenf V 

" " NymphaeOdor ) % ss. 

Add one teaspoonful to a gill of water, inject the ear twice a day. If there 

seems to be thickening, or tendency to ossification : 

$;— Iodid Potass 3 ss. 

Aqua 5 viii. 

Dissolve and inject with this. When the discharge is free and offensive, use 

the following : v 

J^fc— Permanganate Potass grs. ii. 

Aqua Distil Si. 

Wash the ear twice a day. This treatment will prove effectual, and should 
be continued until all symptoms have disappeared. 



DEAFNESS 



May result from various causes — acute inflammation is among the most fre- 
quent causes of deafness. Nearly all diseases of the ear may be traced to 
inflammation and its results. I would earnestly impress upon my readers 
the necessity of controlling all inflammatory conditions of the ear at once, 
not allowing them to pass into any of the terminations or forms of dis- 
ease of the structure of the ear. From the great delicacy of the membrane of 
the ear, there is a great proneness to congestion, and this is liable to occur from 
cold, rheumatism, retrocession, or going in of some eruption, sudden exposure 
to a cold temperature, diving into cold water, irritating substances in the ear. 

Treatment. — The ear, like the eye, is an organ that should not be tampered 
with. In all ordinary cases of inflammation we should give diaphoretic and dif" 
fusive stimulants internally, as : 

$;— Comp. Tinct. Serpentaria ) aa. 

Fid. Ext. Asclepias. j 3 ss. 

Dose. — Twenty drops every two hours. Locally warm applications, the hot 
atomized spray from the atomizer applied directly in the ear. The sap or water 
out of white oak balls, one drop in each ear, will often remove deafness of long 
standing; but for inflammation of the ear of a chronic nature accompanied 
with a discharge, we would advise the comp. syrup of frostwort, with iodide o* 
potass, internally, and locally syringe the ear with a solution of permanganate 
of potass two grains to the ounce of distilled water, and drop in the ear one 
drop of glycerine. 

When due to scrofulous affections of the blood, we must direct our treat- 
ment to the removal of the cause, before we need expect to effect a cure. 



280 Principles ana Practice of 



DISEASES OF. THE CIRCULATORY SYSTEM. 



HEART AND BLOOD VESSELS. 



These, until the commencement of the present century, received but little 
attention. I shall arrange them as follows : 

Inflammatory. — Acute and Chronic. 

Organic. 

Nervous. — Real and Sympathetic. 

The diagnosis of inflammation of the heart or its tissues from that of the 
lungs, is confessedly difficult. In the former, however, we have the pain more 
severe and seated in the region of the heart ; greater deviations in the circula- 
tion and the respiration and the sputa are less affected. 

Pathology. — Though organic changes are chiefly referable to inflammatory 
action, yet some of them qccur independently of it, or, at least without its ordi- 
nary manifestations. Of organic affections there are three varieties : hypertro- 
phy, caused by an excessive supply of blood ; atrophy, caused by an inadequate 
supply ; and alterations of structure, or new formations caused by a vitiation of 
the nutritive functions. Disorganization of the heart may be suspected from 
the following : 

Symptoms.— Bloated face, tumid lips ; the complexion and lips purplish, 
though sometimes florid, or of a waxy pallor, with oedematous swellings, par- 
ticularly about the eyelids ; countenance thin and sharp, eyes prominent and 
staring and the face haggard ; respiration short and difficult, with difficulty 
greatly increased on exertion or mental emotion ; in bad cases an inability to 
maintain the recumbent posture, and sleep disturbed by frightful dreams ; fre- 
quently dyspepsia, and as a consequence, perhaps of the gastric irritation, petu- 
lance and melancholy. But more is to be learned from the circulation. Heart's 
action commonly, though not always irregular, as is betrayed by palpitations and 
great variations in the farce of the pulse. Engorgement of the superficial 
veins, a tumultuous circulation, or a pulsation in the larger veins, especially the 
jugular. Hence occur venous congestions, hemorrhages and dropsies. Primary 
irritation of the heart may be either spasmodic or neuralgic. The former is de- 
noted by the peculiar nature of its pain, sudden remission and the extraordinary 
irregularity of the heart's action. 

The neuralgic affection is denoted by a pain singularly sharp and darting, 
with less disturbance of the heart and pulse. In sympathetic irritation there is 
great disorder of circulation and almost invariably dyspepsia. As consequent 
upon cardiac disease, are the various forms of cerebral disorder — particularly ap- 



American Medicine and Surgery. 281 

oplexy, besides, inflammation or congestion of the pleura, lungs, liver, kidneys, 
uterus ; thickening, or other changes in the alimentary canal, and hemorrhoids. 

Causes. — As is predicable from the peculiar exposure of the heart to corpo- 
real and moral influences, diseases of this organ arc quite numerous. Heredi- 
tary disposition, connected or not connected, with malconformation, there is a 
greater inclination to in the male than in the female. Extreme cold or damp 
weather seems to act as the most prolific cause. 

Rheumatism and gout, misplaced, or metastasic. Excessive labor in doors, 
and in distorted positions of body. The consumption of ardent spirits. A 
stimulating or penurious diet. Inordinate veneral indulgence, or masturbation. 
Recession of cutaneous eruptions — of the exanthematious, and still more of the 
chronic. The strumous diathesis, and the syphilitic taint are alleged causes. 
Affections of other organs, such as various pulmonary diseases, chronic irrita- 
tions of the primae viae, enlargement of the abdominal viscera, pregnancy. Car- 
diac diseases wonderfully increase during times of public terror. So violent is 
the action of the heart when sympathetic of the emotions, that it sometimes 
literally bursts. Besides this, the heart may be affected by whatever acts noxi- 
ously on the system. ■ Hence it is that the pulse is so often appealed to as af- 
fording the most faithful criterion of morbid conditions. 

Diagnosis. — Very obscure. From percussion little aid will be derived. This 
deficiency is in part obviated by auscultation ; auscultation, however, may indi- 
cate lesions of the heart, where none exists ; and, conversely, furnish no signs 
of such, when actually prevailing to a considerable extent. It often gives very 
useful and necessary information, though alone, and without the aid of other 
signs, it cannot, except in some rare instances, show certainly the existence of 
these affections. To acquire the arts of percussion and auscultation, requires 
an ear and training which the practitioner can command only by close study, 
observation and experience. The reader is referred to remarks on auscultation 
in another part of this volume. 

Prognosis. — From the importance of the heart, and the inferior opportunity 
afforded for recovery by its ceaseless motion, cardiac diseases are invested with 
extraordinary danger. Yet some cases may be cured, and others so palliated 
that life may be prolonged with considerable comfort. 

Post Mortem. — The appearances of the heart will be detailed in the consid- 
eration of its specific disease. But whatever the affection may be, provided it 
has been long continued and severe, a sensible increase takes place in the size 
and weight, and of the viscera of the three great cavities. 

Treatment. — Should be most prompt. It is of the first importance to dis- 
tinguish the inflammatory from the purely nervous. The remedies in the former, 
are alterative and evacuant, and subsequently sedative ; in the latter, or nervous, 
they are in most respects the reverse. 



282 Principles and Practice of 



CARDITIS, PERICARDITIS, AND ENDOCARDITIS. 

Inflammation of the fleshy part of the heart is often met with ; still it is much 
less common than pericarditis. The heart and membranes may be simultane- 
ously inflamed, and when any one is exclusively so we have no means of ascer- 
taining the fact with certainty, and if it be done the treatment would be the 
same. 

Symptoms. — Vary much, according to the violence of the attack. The incip- 
ient symptoms are commonly like those of pleuritls, or pneumonia. In the 
more advanced we have an acute, lancinating pain, sense of heat and constric- 
tion in the precordial region, extending to the scapula or shoulder and arm, 
down to the elbow, increased by pressure between the ribs, and by a deep in- 
spiration. Sometimes, however, pain is absent, or it is trivial, or dull and fixed, 
and may be felt in all its states, most in the epigastrium, or left hypo- 
chondrium. 

Inability to change the position, particularly to the left side, or to straighten, 
or lie on it ; restlessness, anxiety, anguish, face pale, or occasionally flushed in 
the left cheek, or tumid, and sometimes leaden, at times bedewed with perspira- 
tion ; a disposition to syncope. Very characteristic is the inability to assume 
the recumbent posture, relief being afforded by the trunk being bent and the 
arms resting on some support in front. Heart usually bounding and forcible; 
pulse strong, full and tense ; though the former may be feeble and irregular, 
and the latter small, corded, intermittent and jerking or thrilling. The pulses 
of the two arms may vary. Urine high-colored and scanty, bowels constipated 
or healthy. • 

Headache, distraction of the senses, jactitation, delirium, distortion of coun- 
tenance, which may assume the expression of terror or despair. Complications 
with inflammation of the lungs, or their connections, or with other affections. 
Cases resulting from sudden metastasis of articular gout, or rheumatism, are 
marked by sharp, spasmodic pain, and laborious action of the heart, with great 
irregularity of circulation, and pulsation in the veins of the neck. 

Causes. — Among these we may mention grief, joy, mental anxiety, violent 
muscular exertions, mechanical injuries, rheumatism, gout, etc. 

Diagnosis. — This is difficult from the frequent complication of other inflam- 
mation of the chest. But in its simple form it is easily recognized. The peculiar 
countenance is very distinctive. 

Endocarditis and fever of the lining membrane of the pericardium are mark- 
ed, like inflammation in other serous tissues, with acute, lancinating pain ; but 
occuring in the fibrous portiohs of the pericardium, or the heart itself, the pain 
is more like a spasm, or it is rheumatic or neuralgic. But endocarditis is said to 
be attended with little pain — with only a feeling of precordial oppression. At 
the same time that the heart's action is tumultuously violent, the pulse is feeble 
and intermittent, and thence rapidly follow extreme debility, great dyspnoea, 
tendency to syncope, etc. In the simple and early character of the diseases there 
is considerable fever, and the state just described, results from the mechanical 



American Medicine and Surgery. 283 

obstruction of the valves which may, from various causes supervene ; or some- 
times, perhaps, from the mixture of secreted pus with the blood. 
• In pericarditis when the effusion has become considerable, there is dullness 
on percussion. The contractions of the ventricles give a stronger impulse and 
a sound more marked than in a natural state. At intervals of various duration 
more feeble and shorter pulsations corresponding to intermissions of the pulse. 
Exceedingly characteristic of pericarditis is commonly held to be the bruit de 
frotement, a sort of rubbing or rustling up and down, compared to the friction 
of silk or parchment. This, at fint, heard faintly, near the centre of the ster- 
num gradually becomes more wide-spread and louder, and is then imitative of 
the creaking of the sole of a new shoe. From the last circumstance it is called 
the leather creak. It is produced by the opposing surfaces of extravasated 
lymph. But the value of this sign is much diminished by its frequent absence, 
its being inaudible, or by its being confounded with what closely resembles it, 
the sound emitted in valvular disease. 

In endocarditis there is dullness of sound on percussion over the precordial 
region, or still greater space. Uniformly present' is the bellows sound. 

Prognosis. — All cardiac inflammations are alarming, of which, however, en- 
docarditis is more so than pericarditis. Life may terminate ,very suddenly and 
unexpectedly. Commonly such diseases, after running a course of several days, 
provided the brain and lungs escape, submit to our remedies entirely, or degen- 
erate into some of those chronic states hereafter to be noticed. 

Post Mortem — The pericardium exhibits redness, arborescent, punctuated 
in patches or diffused. A concrete exudation on its surface, like that in pleurisy, 
though thicker more consistent and rougher. Effusions of serum in the sac 
amounting often to a pint. Sometimes, though rarely, effusions of pus. In 
endocarditis the lining membrane exhibits various colors, from a light rose tint 
to a bright red, or a purple or brownish hue, local or diffused. The inflamma- 
tion is highest about the valves ; and the tumidity there is such as must have 
interrupted the circulation. Discoloration alone is not decisive of inflammation; 
there must be coincident vascularity, or tumefaction, or change of structure, or 
effusions of lymph or pus. Coagula of blood are sometimes met with, which 
when organized are called polypi. The heart itself is generally somewhat tumid, 
vascular, and changed in color. Its surface is often coated with hmph, or 
spread with a collection of purulent matter. The interior of the heart is sel- 
dom much affected. Pulmonary lesions are discoverable in two-thirds of the 
cases. 

Treatment. — In acute cases we should direct an active purgative: 

#— Podorihyllin grs. i. 

Leptandrin grs. ii. 

Bitartrate Potass 9 i. 

Mix. — Give at a dose, and after that an occasional laxative to keep the bow- 
els soluble: 



^fc-Fld. Ext. Asclepias . . . . ) aa. 

" " Serpentaria I 

" " Prun, s Vir ) 3 ss. 



284 Principles and Practice of 

Dose — Thirty drops once in two hours, until free perspiration, alternating with: 

Tr. Cactus Grandiflorus. 

Dose. — Ten drops in water once in two hours, at night. 

^t— Fid. Ext. Cypripedium "1 aa 

" " Lobelia ! '_ 

" " Lactuca it,, 

" " Papaver J 

Z) se. — Thirty drops on retiring. This prevents the spasmodic action of the 
heart and quiets the nervous system. 

In the rheumatic type we should resort to some general line of treatment, as 
directed under that head. Locally : 

#— Tr. Lobelia "1 aa 

' ' Belladonna I '_ 

" Capsicum igj 

" Arnica «. J 

Mix. — Apply over the region of the heart once in three hours, rub well in. 
The diet should be nutritious but unstimulating, perfect hygiene and room well 
ventilated but free from draught. 



CHRONIC CARDITIS, PERICARDITIS, AND ENDOCARDITIS. 

Pathology. — Essentially the same with that of acute carditis. 

Symptoms. — Cases sometimes progress to a considerable extent without at- 
tracting any notice. Generally, however, there is some febrile movement from 
the first, or at least a hectic pulse. A jarring sensation given to the hand when 
placed over the heart, though there is seldom palpitation. Little or no pain in 
the precordial region, and when it does occur it is obtuse and fugitive. But a 
sharp and permanent pain is sometimes felt in the epigastrium, hypogastrium, 
or between the shoulders. The stomach is sometimes irritable, and the head 
aching and giddy. 

Continuing for months or years, the case grows worse, and henceforward 
displays no material distinction from the secondary form of the disease. The 
above is portraiture of the ordinary form, but arthritic and rheumatic cases 
vary considerably. In these is pain more acute and gnawing; greater anxiety 
and oppression in the praecordia; most violent palpitations, with a more dis- 
turbed pulse; excessive dyspnoea upon physical or mental excitement or the re- 
cumbent posture; the disease at first distinctly paroxysmal, and when rheu- 
matic dependent on the states of the weather; peculiar petulance. 

Causes. — Like those of the acute variety, or the disease may be a degenera- 
tion of an acute attack. It is oftener attributable to rheumatism than is the 
acute form. 

Diagnosis. — Still more obscure than in acute carditis. In a large proportion 
of cases a careful investigation will lead to a correct inference. 

Prognosis. — Of very difficult cure, yet not so intractible as to discourage 
our efforts. 

Post Mortem. — 1. A firm adhesion is sometimes found between the pericar- 



American Medicine and Surgery. 285 

dium and heart. The former is usually thicker and more opaque than is natural. 

2. The endocardium is thicker, more condensed, opaque and rough, owing 
either to real hypertrophy or to an adventitious membrane. 

This condition exists in an exaggerated degree about the valvular openings. 
The valves are rendered more or less adherent by lymph. But the valves in 
addition, present divers structural alterations, which will be pointed out sub- 
sequently. 1 

3. The heart itself betrays the evidence of inflammation, chiefly restricted to 
the superficial layer of muscular fibres. Abscesses and ulcers are occasionally 
found in the substance of the organ. But it is sometimes, after the long exist- 
ence of effusion in the pericardial sac, discovered to be in an atrophied condi- 
tion. 

Treatment. — Our best remedy is fid. ext. serpentaria, fifteen drops in a table- 
spoonful of water until we have free perspiration; give once in two hours. Lo- 
cally, the liniment directed in the treatment of the acute form of this disease. 
Constitutional treatment should be alterative and tonic. I would advise 

J&— Syrup Corydalis . 3 iv. 

Iodide of Potass 5 vi. 

Aqua 3 ii. 

Mix.— Dose, one teaspoonful before each meal. Afso: 

J=fc— Fid. Ext. Asclepias Tub 1 QQ 

" Prunis Vir ' aa 

" Cimicifuga [ 5 

" Populus Trem J 3 ss 

Dose. — Twenty drops after each meal. 

Jt*— Fid. Ext. Scutellaria "} aa 

" " Cypripedium J3 ss 

Dose.— Thirty drops in water just before retiring. A purgative at first, sub- 
sequently laxatives, to keep the bowels soluble. The drastics are only of ser- 
vice for the removal of pericardial effusion. 

Simple food in moderate quantities, with mental and bodily quietude, are 
highly important. 

This plan should be persevered in for a considerable length of time, accord- 
ing to Boerhaave's maxim, that chronic diseases require chronic treatment' 
Rheumatic cases are much benefited by a removal from a severe to a mild 
climate. 



HYPERTROPHY. 



This is an increase of the muscular parietes of the heart. 

With this augmentation of the walls, the cavity may retain its natural size, or 
it may be expanded or contracted. The first variety is called simple hypertrophy ; 
the second, eccentric or dilated hypertrophy, or hypertrophy with dilation ; the 
third, concentric, or contracted hypertrophy, or hypertrophy with contraction. 
Hypertrophy may either embrace the entire organ, or it may be restricted to 
parts. 



286 Principles and Practice of 

Pathology. — Hypertrophy may result from healthy nutrition carried to an 
exaggerated degree. 

This state is occasioned by violent and protracted exercise of the organ, which 
enlarges under such circumstances like any other muscle of the body. Or it 
may arise from inflammation particularly rheumatic. In this case the organiza- 
tion is vitiated. 

Symptoms. — The most prominent symptom is the extraordinary force of the 
heart's action, in which the pulse usually participates. The hand, applied to 
the precordial region, experiences a sort of rebound, the end of each shock 
being marked by what is called the back stroke, or diastolic impulse, ascribed* 
• to the refilling of the ventricles. The pulse, owing to the lengthened systole, 
is preternaturally protracted. The capillary system has also an unusual activity, 
as is evinced by a florid or even flushed face, and brilliancy of eye. Occasion- 
ally there is slight dyspnoea, in the advanced stage disorder of system mani- 
fested by a pallid cachectic appearance, flaccidity of the integuments, dropsy, 
with oedema of the face, embarrassed respiration, or still graver pulmonary 
affection. Most characteristic, however, is perhaps the disposition to hem- 
orrhage. No organ or structure maintains an immunity from hemorrhage, 
though the fatal cases a$e most often presented in the form of cerebral or pul- 
monary apoplexy. There is authority for believing that three-sevenths of each 
of these kinds of apoplexies are connected with this condition of the heart. 

Causes. One of the principal causes, perhaps, is dyspnoea, from whatever 
source arising. All violent and habitual exercise. 

Rheumatism, which by the irritation it maintains in the heart, invites an 
afflux of blood to it conducive to an excess of nutrition. , 

This nutrition, being vitiated by the existing morbid action, leads to the 
structural derangement incident to the case. 

Diagnosis. — In general hypertrophy, a rare event, physical exploration re- 
veals only violent action of the heart, and dullness of sound on percussion. 
Of the left ventricle. — This is the most common position of partial hyper- 
trophy. Denoted through the hand, and auscultation, by a very strong impulse 
between the cartilages of the fifth and seventh ribs, to which the strokes of 
the heart are confine 1, and here the sound from percussion is dull. Impulse of 
the ventricle lengthened ; that of the auricle shortened. Of the right ventricle. 
— Stroke perceived most plainly at the bottom of the sternum. The resonance 
is duller, also, in this position. Hypertrophy of the left s : de is more apt to in- 
duce diseases, especially apoplexy of the brain ; while hypertrophy of the right 
rather indicates the lungs. 

Concentric hypertrophy. — Denoted by the dullness and obscurity of the heart's 
sounds, and their limitation to the precordial region. 

Eccentric hypertrophy. — Denoted by clearness of sound, and its diffusion 
over nearly the whole chest. 

Hypertrophy is, in general, more easily distinguished than other cardiac 
affections. It is indicated by the fullness of the .precordial region. From 
dropsy of the pericardial or pleural sac, which also evince this fullness, it may 
by many symptoms be discriminated. 



American Medicine and Surgery. 287 

Prognosis. — By proper and early treatment, the disease is usually cured. It 
may at other times be so checked that the patient may live to old age without 
any serious inconvenience. Children are apt to outgrow it. The disease some- 
times proves fatal from the supervention of cerebral or pulmonary apoplexy, or 
from hemorrhage or hydropic effusions. 

Post Mortem. — The heart may increase in size three or four times, or from 
eight or nine ounces it may weigh as many pounds. 

The substance of the heart is redder than natural, and the coronary arteries 
are tinged. The external and internal surfaces occasionally exhibit evidences 
of inflammation. 

Treatment. — Keep the circulation equalized, and to this end we would 
recommend : 

ii— Fid. Ext. Serpentaria ~) aa 

" " Asclepias 

" " Prunis Vir J 3 ss 

Dose. — Thirty to sixty drops three or four times a day. Where we have 
debilitated condition of patient, give the syrup hypophosphites, soda, lime, 
potass, and iron, nitro-muriatic acid, fifteen drops of the diluted preparation, 
half an hour after meals. Alteratives, and the treatment directed in chronic 
carditis. • 



DILATATION OF THE HEART. 

Hypertrophy of the heart, with dilatation known as active dilatation, where 
the expansion predominates over the hypertrophy ; simple dilatation, where the 
thxkness of the walls are normal ; passive dilatation, where the walls are 
thinned — conditions often combined with mal-nutrition of the heart, and fatty 
degeneration of the muscular fibre. It is generally found in weak constitu- 
tions, or in persons of impaired health. The symptoms are consequently much 
modified and complicated by associate affections. 

Pathology. — Dilatation is immediately owing to deficiency in the muscular 
powers of the heart, and obstruction in the circulation, inducing accumulations 
of blood in the cavities of that organ, whereby through mechanical pressure 
the cavities are amplified, and the parieties attenuated. 

Symptoms. — Early in the attack, where this is slight, and the system in a 
state of tolerable integrity, the disease is difficult of recognition. A sense of 
weight and uneasiness in the prsecordial region, or more extensively, feeble pal- 
pitations, pulse generally soft, small and slow ; frequent and violent dyspnoea, 
with cough and copious expectorations, as in bronchitis, or humoral asthma, 
face pale and waxy, though occasionally livid, and the extremities cold ; 
turgescency of the veins, particularly the external jugular, and consequent on 
this congestion hemorrhages and dropsies, senses and mental faculties obtuse, 
headaches apparently from fulness, and sometimes stupor, convulsions or ap- 
oplexy. 

This disease is not always so violent as has been represented ; some of the 



288 Principles and Practice of 

most severe affections occurring only during the paroxysms, to which the disease 
is very liable. 

Causes. — Whatever seriously and permanently impedes the circulation — as 
valvular diseases of the heart, liver, etc. Whatever disturbs the heart's action, 
particularly a vitiated state of the blood. But, in addition there must be a pre- 
disposition in the organ to such alterations. 

Diagnosis. — Sometimes difficult, when the case is embarrassed with compli- 
cations. 

Distinguish it from, hypertrophy, bv the passive nature of its symptoms. 
From engorgement of the cavities of the heart, by the less round, equable, 
compressible distension of the precordial region and by its permanency. 
From nervous irritation, by its permanency. But it is necessary in these 
cases to collate all the symptoms. Respecting the reputed physical signs in 
this affection, some prove nothing very decisive, and the rest are fallacious. 

prognosis. — A dangerous and intractable disease, particularly when con- 
nected with contamination of body, or the destructive lesions to be mentioned. 

Post Mortem. — Increased size of the heart ; paleness and flabbiness, or soft- 
ening of its substance, attenuation of its walls ; disease of the valves, septum, 
and columnae carnas. These changes may be universal, or embrace only a par- 
ticular auricle or ventricle. Besides we meet with a multitude of lesions of the 
lungs and abdominal viscera. 

Treatment. — The chief indications are, to rectify any abnormal conditions 
and improve the general well-being of the patient. Aid digestion with such 
tonics as hydrastia and cinchona. Stimulate the skin with warm medicated 
baths ; remove existing tendency to hypertrophy with : 

#- Syr. Stillingia Comp '. i. 

Iodide Potass 5 i. 

Dose. — One teaspoonful three times a day. To promote muscular force — 

#-Fld. Ext. Prunus Vir "J aa. 

" " Asclepias J 3 i. 

Dose. — Thirty drops three or four times a day. Nervous irritation may be 
calmed by: ' 

fy— Fid. Ext Cypripedium . . ^ aa. 



" "Lobelia J 5 i. 

Tr. Capsicum 5 ss. 

Dose. — Thirty drops just before retiring. To impart energy to the muscular 
fibre of the heart, the tr. cactus grandifloris is splendid, ten to fifteen drops three 
or four times a day, also nux vomica. The irritating plaster over the spine 
between the shoulders. 



American Medicine and Surgery. 289, 



ATROPHY OF THE HEART. 

Symptoms. — Action of the heart very feeble, propensity to syncope, and the 
characteristics of the general pathological condition with which the cardiac dis- 
ease is associated. 

Causes. — Whatever produces a general marasmus of the body, the pressure of 
liquid effused into the pericardium, ossification of the coronary arteries. 

Diagnosis. — The disease cannot be certainly determined. 

Prognosis. — Commonly fatal. 

Post Mortem. — The heart has been found diminished to half its normal size,, 
and wrinkled. 

Pathology and Treatment. — The opposite to those of hypertrophy. 



RUPTURE OF THE HEART. 

Symptoms. — These may be those of the pathological condition of which it is 
the effect, though sometimes the rupture occurs without any previous symp- 
toms. 

Causes. — Occurs mostly among males and old people. The rupture is imme- 
diately excited by whatever produces strong action of the heart. 

Diagnosis. — Distinguished from cerebral apoplexy by the instantaneousness 
of death, and pallidness of the countenance. 

Prognosis. — Nearly always fatal ; perhaps when the rupture extends through- 
out the whole thickness, always so. 

Post Mortem. — Besides the rupture we may discover ulcers, softening, partial 
atrophy, or partial hypertrophy. 

Treatment. — Incurable. 



CARDIAC VALVULAR DISEASE. 

The frequency and fatal results of valvular disease, should never be lost sight" 
of. The heart is a single organ, with the one function of propelling the blood 
through the system. It consists of a number of parts, each dependent upon' 
the other for action. If the ventricle or valves of the left are injured, the right 
cannot do their work. 

Unlike most other organs, one part cannot take the place of another, rest is 
impossible ; no repairing process here. We may enjoy tolerable health with 
one lung impaired, with one kidney not acting, or performing its functions, but 
no disease of the heart can be compensated for in any way. Inflammatory at- 
tacks, rheumatism, gout, insufficient food, mental anxiety, overwork, alcoholic 
stimulants, tobacco, violent exercise, are among the exciting causes of disease 
of the valvular structure. 
19 



290 • • Principles and Practice of 

Pathology. — All the internal alterations in the heart result from inflammation. 
This gives rise to a deposit of lymph, or matter beneath the serous membranes 
and in this way the valves lose their transparency, and become thick, puckered 
and adhering to each other. The valves often become covered with exudations, 
vegetation or excrescences, become ossified, or the seat of calcareous deposits. 
The natural result is a contraction or narrowing of the orifice, obstructing the 
passage of the blood ; valvular obstruction, or we may have thickening or 
shortening of the valves to make the orifice more or less potent and permit re- 
gurgitation of blood, valvular insufficiency, regurgitation, valvular obstruction, 
or insufficiency, often exist at the same time. 

Symptoms. — In valvular disease we have difficulty of breathing, increased by 
exertion, palpitation, and irregular action of the heart, with abnormal sound or 
murmuring, detected by application of the ear over the heart, attenuation in the 
pulse, soft and irregular in mitral disease ; hard and jerking but regular in dis- 
eases of the aorta. Congestion of the lungs, bronchitis, pneumonia, hemorrhage 
from nose, bronchi and stomach, oedema of lower extremities, arms, face, etc., 
dropsical effusion of feet, legs, stomach and abdomen ; headache, neuralgia, 
and constant noise in the ears. 

We usually have broken rest, frightful dreams, enlargement of the liver and 
spleen may ensue, digestion is impaired, cheeks puffed, lips red or purple, eyes 
assume a peculiar bright appearance. As the disease advances, patient becomes 
weak, nervous, suffers from over-exertion, mental emotion, food, exposure, etc. 
Death, usually, may be attributed, not directly to the disease of the heart, but 
to some secondary disease. 

Causes. — Over-action of the heart and the ordinary causes of inflammation 
and perverted nutrition. 

Diagnosis. — Both sounds of the heart are accompanied with bellows-murmur, 
harsh, rasping, cooing or whistling. The different sounds are caused by some 
obstruction to the free flow of the blood. The true sounds — diastole and sys- 
tole, are the result of the free flow of blood and healthy action of the heart. 
The diastole sound is produced by a dilation, or spreading out of the heart and 
arteries, when the blood enters the cavities ; systole, when these organs con- 
tract to send forth the blood. 

Prognosis. — Always formidable, though taken in the commencement, and 
where it is dependent on mere thickening from chronic inflammation, it may 
be removed. 

Post Mortem. — A part, or the whole, of the valves, are found altered in 
shape, and, in cases of long standing, converted from mere thickening into fibro- 
cartilage, cartilage, or osseous or calcareous substance. The aperture is some- 
times much contracted by the altered form of the valve. 

Vegetations may also exist along the basis and free margins of the valves. 
Besides there often co-exist other organic changes in the heart and other organs. 

Treatment, — Must be directed to control the inordinate action of the heart 
to ward off or relieve the other symptoms as they appear, impart tone and 
strength to the general system — to the heart especially. When we have drop- 
sical effusions, give : 



American Medicine and Surgery. 291 

#— Podophyllin grs. x. 

Leptandrin i xx 

Bitartrate Potass 3 ss. 

Mix and make ten powders. Give one morning and night. Give occasionally 
a teaspoonful bitartrate potass, in a wineglass of water, with eight or ten drops 
of cactus grandifloris, alkaline bath, three to six times a week. In addition we 
want something to act on the blood — increase the quantity and improve the 
quality. If the case does not improve, 1 have found the following very good .." 

JE*— Fid. Ext. Buchu 1 

" " Uva Ursi j aa. 

" " Hydrangea \ 

" " Eupatorium Pur | 3 ii. 

" " Cimicifuga J 

Mix — Dose. — One teaspoonful every three hours during the day, and to ten 
o'clock at night. As a tonic we should give cinchona comp. with phosphorus, 
as follows : 

J£t— Tr. Cinchona Comp 5 viii. 

Acid Phos. Dil 3 ii. 

Syrup Simplex 3 vi. 

Mix. — Dose. — One teaspoonful before each meal. This may be alternated 
with fluid ext. of prunus virginicus. Dose, twenty drops after meals. 

A. good, nutritious diet is one of the best remedies, and should not be lost 
sight of. 



NERVOUS AFFECTIONS OF THE HEART. 

PALPITATIONS 

May be more violent than palpitations from organic disease. 

Pathology. — The palpitations, at first merely irritative, may afterwards, as 
we are assured, lead to disorganization of the heart. 

Causes. — Either a nervous or sanguine temperament, either a full or an 
anaemic condition, exhibits a predisposition. As exciting causes of temporary 
palpitations may be enumerated mental agitation, physical exertion, stimulants, 
indigestible food, the habitual use of opium, or of tobacco in any form. 

Chronic palpitations generally arise from an irritation derived from some of 
the abdominal or other viscera, spinal irritation, hyperaemia, or anaemia. 

Diagnosis. — Quick, strong, irregular action of the heart and pulse, which is 
very apt to be intermittent, a sense of agitation throughout the epigastrium and 
in the head, palpitations experienced more in repose than when up and moving 
about, sometimes continued the greater part of the night, increased by lying 
on the left side, often gastric disorder, a disposition to urinate, the discharge 
being. pellucid and copious. Again, we may conduct a diagnosis by exclusion, 
discovering that the palpitations do not proceed from any particular organic 
disease. In nervous palpitations, the impulse, apparently great, is really mod- 
erate, and rarely repels the hand when placed over the cardiac region. The 
effect of anti-spasmodics is also very diagnostic. 



292 Principles and Practice of 

Prognosis. — These palpitations generally do not lead to any serious conse- 
quence. 

Post Mortem. — Sometimes, perhaps, hypertrophy, or dilatation, as an effect 
and serious disease of the chylopoietic viscera, or lungs, as a cause. 

Treatment. — The palpitation being brought on suddenly from moral emo- 
tion, or inordinate physical exercise, the individual should rest for some time, 
and may in addition resort to a nervine in the former, and a mild purgative in 
the latter case. Proceeding from gastric disorder, employ an emetic, or, if suf- 
ficient, an antacid. In the chronic form we must address our treatment to the 
disorder, whatever it may be, of which the palpitation is an effect. The 
paroxysms are to be appeased when they occur. 



ANGINA PECTORIS. 

This is the disease in which great pain is felt about the chest, with a sensation 
of oppression and strangulation. It frequently appears in advanced life, and is 
more common among men than women. It is often associated with hyper- 
trophy or enlargement of the heart, fatty degeneration, dilation of the heart, 
and diseases of the coronary arteries. There are several forms, and it may 
appear independent of structural causes. » 

Persons of a rheumatic or gouty diathesis are more subject to it than 
others. 

Pathology. — The true pathology of angina pectoris is that it is an affection of 
the nerves that supply the heart, stomach and lungs. 

It has its origin in a rheumatic or neuralgic tendency, involving mainly the 
pneumogastric nerve and the branches communicating and connecting with the 
heart and stomach. 

Symptoms. — The general symptoms are paroxysms of intense pain and con- 
striction about the heart, in fact, the pain and constriction are such that it is 
often mistaken for asthma. Those attacked with angina pectoris h ave a pecul- 
iar horror of impending death, and no doubt suffer all the pangs of dissolution 
The attacks seldom last more than a few minutes ; it may come on at any time. 
If the patient is walking he is compelled to stop at once. Upon examination, 
the pulse will be found slow and intermitting, the breathing short and hurried, 
countenance pale and "dejected, surface of the body cold, or covered with clam- 
my sweat, consciousness unimpaired. When the paroxysm passes off, the pa- 
tient regains his usual health ; but without prompt relief the disease finally 
proves fatal. 

There are two forms of the disease — acute and chronic. The acute form is 
sudden in its attacks, severe pain in the region of the heart, extending to the 
shoulder, arm, wrist and fingers. When angina pectoris arises from hypertrophy 
of the heart there are powerful pulsations of that organ, which can be seen at 
a distance. When it arises from dilation of the ventricles, there is extra heavy 
pulsation of the jugular vein, vertigo and weak pulse. When connected with 



American Medicine and Surgery. 293 

disease of the valve of the heart, there will be difficult breathing, feeble irregu- 
lar pulse, haggard appearance, swelling of the feet and ankles. 

If the disease is chronic, the paroxysms occur frequently — the most trifling 
cause may produce it. The pain involves both arms, and ascends to the jaws. 
It is always aggravated by the slightest movement, and a neuralgic pain is 
usually present under the breast bone. It is only distinguished from asthma by 
the acute and peculiar pain in the breast bone and left arm, and by the different 
surroundings or causes of such disease. The shortness of breath in asthma is 
dependent upon spasmodic contraction of the muscular fibres and their branches. 
In angina pectoris the pain resembles neuralgic pain more than any thing else. 

Treatment. — If we see the patient durir.g the paroxysm, our best resort is 
diffusable stimulents, such as brandy, wine, tinct. capsicum, tinct. zanthoxylum, 
etc. Place the patient in bed, give small dose of cactus grandiflorus or fid. ext. 
lobelia, ten to fifteen drops every three hours until relieved. Counter-irritants 
between the shoulders is good ; also, active friction with stimulating liniment, 
salt-water, etc. The treatment in the interval between attacks should be al- 
ternated between tonics and alteratives. The following is good : 

fy— Syrup Iris Versicol Comp O i. 

Dose. — One teaspoonful in water before each meal. Give at the same time : 

J^fc— Tr. Ferri Chloride ") aa, 

" Hydrastis Can ) 5 ss. 

Dose. — Twenty drops in water half hour after meals. Avoid all alcoholic 
stimulants, as they only aggravate the disease. The syrup of hypophosphitis is 
excellent. 

Fid. ext. of valerian, or prunus vir is good. The chances of a cure de- 
pend upon the cause of the disease. If it arises from organic affection of 
the heart, we cannot promise more than relief ; but if dependent upon dis- 
ease of the pneumogastric or cardiac nerve, then we can administer remedies 
with a fair prospect of success. When the disease arises from affections of the 
nervous system, give fid ext. valerian, forty drops before meals, and tinct. nux 
vomica, ten drops after meals. A good diet is essential to the final success of 
any treatment. 



ACUTE ARTERITIS, OR INFLAMMATION OF THE ARTERIES. 

Pathology. — Mere redness is not to be regarded as proof of previous inflam- 
mation, since this appearance often takes place after death, particularly in 
typhoid cases, and where the blood is preternaturally fluid. 

Symptoms. — The disease as an idiopathic affection, being very rare, its symp- 
toms are not very well understood. They are said, however, to consist in a ve- 
hemence of pulsation in the inflamed vessels : a sense of heat and pain along 
its course, with a corresponding streak of redness ; extreme pain on pressure. 

As general symptoms, we have extreme restlessness, nausea and faintness, 
and where the aorta or pulmonary artery is concerned, dyspnoea, cough, and 
thoracic pain are apt to be present. 



2Q4 Principles and Practice of 

Causes. — Probably those of cardiac inflammation. More generally it pro- 
ceeds from an extension of pulmonary, cardiac, or abdominal inflammation. 

Diagnosis. — There can be no positive discrimination of internal arteritis. 

Prognosis. — The severer forms of the disease often fatal. The chief danger 
proceeds from the obliteration of the artery from effused lymph, or from the 
diffusion of the pus secreted by it, or softening, or other or ganic changes of its 
texture. 

Post Mortem. — The most common appearances are redness of the interior 
membrane, interspersed with white spots ; occasional extravasations of lymph, 
and depositions of pus ; and thickening ramollescence, and ulceration of the 
arterial surface. 

In inflammation of the great arteries within the chest, these appearances may 
be extended to the heart. Indeed the red staining sometimes pervades the 
vessels, and hence has probably arisen the erroneous notion of fever being de- 
pendent on arteritis. 

Treatment. — Same as that of similar inflammation of the heart. 

The arteries are subject to chronic inflammation, which, though some 
authorities constitute it the most common affe;tion, I am of the opinion is a 
comparatively rare event. By those who hold the other notion, it is probably 
made to include 

DEGENERATION OF ARTERIES. 

These consist of extraneous deposits of fibrous steatomatous, cartilaginous, 
calcareous, osseous and other matters. From such metamorphosis no artery 
is exempt, but the remarks are here confined to the arteries of the cavities. The 
artery most usually thus affected is the aorta, and next are the cerebral arteries, 
by which is laid, as is now believed, the foundation in the majority of cases of 
cerebral apoplexy and some of epilepsy. The pulmonary artery is seldom 
thus involved. 

Pathology. — When consolidation merely has taken place in consequence of 
the infiltration of lymph or albumen, it is the effect of inflammation ; but where 
the identity of structure has been lost, then the change is referable to a vitiation 
of the nutritive process. 

Symptoms. — The disease is seldom betrayed by any marked symptoms until it 
has reached a considerable height. Subsequently we have that sort of distress 
and other effects, which proceed from an embarrassed circulation. 

Causes. — The affection most incident to old age — particularly ossification. 
Other causes are the long prevalence of gout or rheumatism, syphilis, the abuse 
of mercury, intemperance in eating or drinking, and perhaps hereditary influ- 
ence. But often these changes occur without any appreciable cause. 

Diagnosis. — We cannot, either by symptoms or physical signs, diagnosticate 
this disease with certainty. 

Prognosis. — Generally incurable. 

Post Mortem. — The deposit is between the coats. Sometimes several kinds 
of degeneration are exhibited at the same time, the case progressing from the 
softer to the harder deposits. Of the aorta, the beginning and arch are mostly 
affected. 



American Medicine and Surgery. 295 

Treatment. — At an advanced period, little can be anticipated besides mere 
palliation. The measures are not materially different from those to be pursued 
inorganic diseases of the heart. 



ANEURISM OF THE ARTERIES. 

By aneurism is meant a dilatation of an artery. This may occur from the 
simultaneous distention of all the coats, or by some of them giving way, caus- 
ing an extravasation of blood, or by a solution of continuity in the interior 
coats, while the outer one maintains its integrity. These forms receive the 
respective names true, false and mixed aneurism. 

Here will be considered aneurism of the internal vessels only. They are all 
liable to the affection, but the aorta being pre-eminently so, will be mainly re- 
garded. The lesion is nearly always found either in ascending portion or arch. 

Pathology. — From a loss of contractility, the pressure of the blood gives rise 
to permanent dilatation. 

Symptoms. — Being deep-seated and small, it is said to be not detectible 
and death may give the first intimation of disease. Being, however, more de- 
veloped the symptoms are cachectic aspect, palpitations or other strong pulsa- 
tions, dyspnoea, cough, disturbed sleep, a tendency to syncope, irregular distri- 
butions of blood creative of congestions, and sometimes lividity of countenance, 
passive hemorrhage and serous effusions. These symptoms though common to 
many of the cardiac affections are apt to be more intense. 

Causes. — Like those of associated cardiac affections and spontaneous aneu- 
rism in external arteries. 

Diagnosis. — Very pathognomonic when it exists, is a tumor-like prominence 
in the situation of the aneurism with a heaving pulsation The paroxysmal oc- 
currence of the symptoms best distinguishes the nervous affections which re- 
semble aneurism in their manifestations. 

Percussion at the top of the sternum may elicit a dull sound, and through 
the stethoscope applied to the same region, we may discover a loud, rough or 
abrupt bellows sound, or a purring murmur, or a slight whizzing. 

Prognosis. — Incurable by art, aneurism of internal vessels, and even the aorta 
is occasionally cured by nature from the coagulation of blood in the sac, and 
its ultimate conversion into a small, dense, tumoroid mass. 

Post Mortein. — The artery having been ruptured, we discover the blood in 
one or more of the contiguous organs. The parieties may be found either at- 
tenuated or thickened. The rupture may occur from the tenuity of the pari- 
eties from ulceration. When the aneurism is large, surrounding parts are re- 
moved by absorption excited by the pressure. Even bone itself cannot resist. 
Ossification or other degenerations in other parts of the artery may be associ- 
ated. The pulmonary artery is rarely affected. 

Treatment. — Nature points clearly and emphatically as to the mode of cure, 
the throwing out of coagulable lymph, which, with the fibrine of the blood, 



296 Principles and Practice of 

forms a layer more or less organized on the inner surface of the aneurismal 
tumors ; this gives rise to membranous bands, which shoot down from all parts 
of the walls of the sac, which tend to retard the blood in its meshes, and trms 
aids coagulation. Every thing that improves the health will aid this process — 
highly animalized diet, beef, eggs, oysters, milk. Improve the vital energies by 
cinchonia, iron, nitro-muriatic acid, phosphorus, but restrain or retard the action 
of the hearty keep the circulation at 65 or 70, strict quietness of mind and body, 
change of air, regular secretions. 
If this does not succeed, give : 

J£t— Tr. Cactus Grandiflorus . . "> aa. 

Fid. Extract Prunis Vir j 3 ss. 

Dose. — Twenty drops once in three or four hours, alternate with : 

J$c— Fid. Ext. Myrica : "] aa. 

" " Nymphia J 3 ss. 

Dose. — Thirty drops three times a day. 

Pressure upon the artery above the tumor has succeeded. It mechanically 
diminishes the flow of blood through the sac ; it physiologically enables the 
fibrine to coalesce and become easily and readily entangled in the parieties of 
the sac, and if the case is managed judiciously, this will increase until the 
contents of the tumor solidifies, and the circulation may be carried on by the 
natural channel, or else obliteration may occur at the point ; then the collateral 
branches become enlarged — the circulation is carried on by them. Compression 
is best effected by two or three instruments with graduated compresses. 

A ligature applied to the artery, at some distance above the aneurismal tumor, 
cuts off the current, the pulsation in the tumor at once ceases, fibrinous coagula 
are diminished by absorption, and gradually degenerates into an impervious 
cord. 

Electricity has been successful in producing coagulation of the aneurismal 
tumor. An injection of the following will produce instantaneous coagulation : 

It— Glycerine 5 iv. 

Carbolic Acid 5 i. 

Mix. — Inject two or four drams, according to the size of the tumor. But 
of all modes of cure, I am most partial to constitutional means. 

Fibrinize the blood, restrain the circulation, and coagulation is certain. 



PHLEBITIS. 



Once a very common disease, especially when bleeding was resorted to for every 
disease, inflammation of the vein was a common result. It is rarely met with 
now, and is usually due to an abrasion, scratch or irritation, with which some 
poisonous matter has come in contact. 



American Medicine and Surgery. 297 

Treatment. — No matter to what cause the inflammation is due, there is no 
remedy like the sulphite of soda. Give : 

• ^i— Tr. Capsicum ) aa. 



" Lobelia ) 3 ss. 

Fid. Ext. Asclepias 3 i. 

Dose. — Thirty drops three times a day before each meal, and the sulphite of 
soda, ten grains, half hour after meals. Give beef tea, eggs, cream, etc. Locally 
paint over the corded vein with creosote or carbolic acid, until white, then pcultice 
with flax seed, and a cure is soon effected. 



298 Principles and Practice of 



DISEASES OF THE ALIMENTARY SYSTEM. 



INFLAMMATION OF THE TONGUE. 

Glossitis, or inflammation of the substance of the tongue, is usually de- 
pendent upon some constitutional cause or some irritant applied directly to the 
part In either case there is fever, great nervous depression and debility. In 
all cases, the local symptoms are those of pain, heat, redness, swelling — the 
tongue protrudes out of the mouth. 

It comes on quickly, and is often attended with urgent symptoms, and re- 
quires prompt treatment, active purgatives, and diaphoretics administered per 
rectum, if unable to swallow, ext. of lobelia and asclepias, in combination should 
be given in say thirty drop dose every two hours, mucilages of elm should be 
applied to the tongue. If impending sense of suffocation takes place, tracheo- 
tomy should be resorted to. 

If it comes on from mercury, chlorate potassa, iodide potass, internally with 
baths of sulphur soap. 

Ulcers or patches on the tongue are generally due to mal-nutrition and come 
properly under the head of apthae. Warts and condylomate are not uncom- 
mon on the tongue in syphilitic affections. They should be destroyed and the 
diseased condition treated with alteratives. 



INFLAMMATION OF THE MOUTH. 

This is occasionally met with in children, depends commonly on mal-nutri. 
tion, and is usually seen as follicular ulcerative and gangrenous and stomatitis. 

The treatment in all cases consists in perfect cleanliness, fresh air, thorough 
hygiene, antiseptics, tonics, alteratives, nutritious diet, and gargles of gold 
thread, or permanganate potass. 



APTH.E. 



However harmless the sore mouth may be considered, it is undoubtedly a 
disease of debility arising from acidities in the first passages, or some other 
acrimonious humor lodged in the stomach and bowels, or from indigestion 
whether occasioned by bad milk or other unwholesome food. This disorder 
generally appears first in the angles of the lips, and then on the tongue and 
cheeks, in the form of little white specks. These increasing in number and 
size, run together more or less, according to the degree of malignity, composing 



American Medicine and Surgery. 299 

a thin white crust, which at length lines the whole inside of the mouth, and ex- 
tends into the stomach and through the whole intestinal canal, producing, also, a 
redness about the anus. If the specks are of a pale color, superficial, and easily 
fall off, they are not considered dangerous; but when the crust falls off, and is 
succeeded by another of a darker color, or livid hue, it is reckoned the worst 
kind. In forming our prognosis of the termination of the disease, it is neces- 
sary to attend to the sensibility of the stomach and bowels, and the appearance 
of the egestion. 

Frequent vomiting, repeated thin stools, with griping and tender state of the 
abdomen, are very unfavorable ; drowsiness, oppressed breathing, moaning, 
spasms, and great languor, with frequent pulse, are symptoms indicating danger- 
A remarkable propensity to sleep, frerfulness when awake, and an unusual heat 
in the mouth, are among the premonitory symptoms of fatal termination of the 
disease. In its mild form, or when it is an original disorder, it is never attended 
with any fever ; but when it has arisen in consequence of severe bowel com- 
plaints, or other infantile diseases, it is not unusual in such cases for the thrush 
to be accompanied with fever of the low kind. In mild and recent cases of 
this disease, when the apthse is confined to the mouth, and appears in a few 
scattered spots resembling little pieces of curd sticking to the surface of the 
tongue, or within the lips, it may in general be easily removed by keeping the 
bowels duly open with syrup rhubarb et potass, given daily. 

Many regard apthae as a salutary complaint, and in consequence of this er- 
roneous belief, the disease has been neglected until it has extended down to the 
stomach and intestines, producing cough, and great difficulty of breathing, with 
other symptoms of a disordered state of the stomach and bowels. Under these 
circumstances the most active remedies must be employed or we shall be 
unable to arrest its fatal termination. 

Treatment. — Give the little sufferer an emetic at least twice a week. After 
the action of the first emetic, put it upon the following : 

#— Syr. Rhei et Potass 3 iii. 

Fid. Ext. Serpentaria 3 ss. 

Sulphite Soda .5 ss. 

Dose. — Half a teaspoonful every three hours. To the apthous spots, where not 
deep seated, apply : 

4*— Fid. Ext. Myrica 5 i. 

" ■' Baptisia 5 ss. 

Mix. — Add one teaspoonful to a fill of water, and wash the mouth once in 
three hours, or instead use a saturated solution of sulphite of soda to the 
apthous spots. This local treatment should be kept up for some time, until we 
rectify the diathesis and bring about healthy nutrition. After we have brought 
about a change both in the ulcer and in the process of assimilation, then a 
lotion of : 

^fc— Sulph. Hydrastis grs. x. 

Aqua Camphor 3 iii. 

Apply to the spots, or wash out the mouth three to four times every day. 



300 Principles and Practice of 

Local treatment will fail unless assisted with proper constitutional remedies. 
Our best remedies are those that rectify acidity and promote assimilation, as : 

I?fc— Syr. Hypophosphite comp. 

Dose. — One-half to one teaspoonful three times a day. We might alternate, 
after giving hypophosphite for a few days, with : 

9; — Glycerine 5 iv. 

Acid phos. Dil 5 ii. 

Mix. — Dose. — Half a teaspoonful thrice daily. Baths are important, daily ^It- 
water bath, friction, warm clothing, exercise, fresh air. Hygiene perfect and 
thorough. The diet must be the best, one that is calculated to promote health. It 
must be as nutritious as can be digested and assimilated ; it should include beef, 
oysters, poultry, Liebig's food, milk, eggs. 

Besides the above form of apthae due to mal-nutrition, we may have a variety 
of other forms dependent upon some specific poison in the blood, as the poison 
of syphilis, lead-mercury, tubercle, etc. ; these give rise to molecular inflamma- 
tion of mucus membrane giving us syphilitic apthae, lead and mercurial apthae. 
All varieties of apthas are essentially contagious and infectious in a direct com- 
munication of the poison that gives rise to ulceration ; these varieties of apthae 
should be treated by destroying the ulcers with nitric acid, by gargles of myrica 
cerifera, gold thread, hydrastis, and in all cases antiseptics must be administered 
to correct mal-assimilation. Out best antiseptics for this purpose are yeast, 
baptisia and sulphite of soda. 

Otherwise the case must be managed on general principles; if syphilitica 
general alterative and tonic treatment is indispensable ; if lead and mercury be 
present, iodide of potassium in some vegetable alteratives with alkaline baths ; 
if due to tubercle, syrup of hypophosphites comp. 

Cancrum Oris. — This may be the result of" apthae, provided the patient is 
subject to overcrowding, absence of all sanitary and hygienic surroundings, the 
generation of an animal poison superadded to the irritation of the ulcer which 
gives apthae a gangrenous or phagedenic condition. The poisonous matter in 
connection with the pus from the ulcers are swallowed, causing ulceration of 
gums, cheeks, oesophagus, stomach, bowels, putrid diarrhoea, offensive breath. 
The treatment is the same as apthae, not omiting antiseptics to destroy the 
septic poison which produces such destructive ravages. 



BUCCAL GLANDS. 



The mucous follicles, seated in the buccal membrane, opposite the molar 
teeth, are often the seat of tubercular deposit, which forms quite an impedi- 
ment to the proper function of the mouth, as their secretion is arrested and the 
mouth imperfectly lubricated. I have met with a number of cases. 

The remedies to be depended on are alteratives, etc. 

Peculiar cases have occurred that resisted all treatment for a period of years, 
and suddenly yielded to the administration of iodine and phosphorus. The 
following is a good method of administering iodine : 



American Medicine and Surgery. 301 

#— Comp. Syr. Stillingia j O ss. 

FJd. Ext. Alnus Rub i aa. 

" '• Iris Versicol fsss. 

Iodide Potass « 5 ss. 

Mix. — Dose. — One teaspoonful three times a day. Locally : 

J£k— Uneuentum Phytolacca g i. 

Muriate Ammonia 5 iij. 

Iodide Potassa 5 iv. 

Mix. — Spread on leather and keep constantly applied. Give : 

#— Fid. Ext. Prinos ) aa. 

AcidPbosDil \ 

Syrup Simplex O ss ) 5 ii. 

Dose. — One teaspoonful three times a day after meals ; the best diet, thorough 
hygiene, warm clothing, fresh air. 



TONSILITIS. 



Inflammation of the tonsils, prevalent during spring and autumn, when the 
weather is variable, sudden changes, etc. 

Symptoms. — Heat, and dryness in the throat, preceded by chilly, shivering 
sensation ; throat filled with mucus, glands in the jaw become swollen, hawk- 
ing, spitting, and constant effort to swallow, attended with pain, respiration is 
difficult and hard, feverish symptoms. 

Duration is from six to twelve days. 

A person who has had several attacks of tonsilitis may have it without any 
constitutional implication. This is true also when the habit is scrofulous. But 
ordinarily the disease soon terminates in resolution, suppuration, or induration. 
In some cases the inflammation is very superficial and diffusive, like that of 
erysipelas. 

Causes.— Cold and damp air, or cold in any manner applied, so as to cause a 
sudden check of the perspiration, may be regarded as the exclusive cause of 
this disease. 

Persons become predisposed to the disease by suffering an attack of it. The 
principal danger arises from the swelling of the tonsils, which may proceed to 
the extent of entirely interrupting respiration. 

When it does not end in resolution, it almost always terminates in suppura- 
tion. Frequent attacks of the disease are apt to produce permanent enlarge- 
ment of the tonsils. The inflammation has been known to extend into the 
larynx, in which case the danger is greatly increased. 

Treatment. — In acute cases we would give an emetic of lobelia comp. and 
follow with : 



#— Fid. Ext. Serpentaria 

" " Asclepias 

Tr. Capsicum J I ss. 



."> aa. 
. j | Si 

Dose. — Twenty drops in water every two hours. 



302 Principles and Practice of 

Locally we would use as a gargle : 

R— Tr. Capsicum "] 

Fid. Ext Baptisia j aa " 

" Xanthoxylum i ♦. [ , 

" " Myrica Cer j 5 ss. 

Mix, and add one teaspoonful to a half pint of water. Use as a gargle 
every three hours. , Externally : 

R— Tr. Belladonna ) aa. 

' ' Arnica V 

Aqua Ammonia ) 3 ii. 

Rub well in over the region of the pain. In chronic tonsilitis we would put 
the patient on a thorough alterative course, as : 

ft— Syr. Stillingia comp O i. 

Iodide Potass 2 ss. 

Dose. — One teaspoonful before each meal. 

ft— Tr Sanguinaria "1 aa 

Fid. Ext Xanthoxylum [ ^_ 

" '• Asclepias f » •• 

" " Dracontium J 3 

Dose. — Twenty drops three times a day in sugar and water. Meet other 
indications as they arise, building up the general health with tonics, nutritious 
diet, etc. 



PAROTITIS. 



Inflammation and tumefaction of the parotid glands, occasionally epidemic 
and manifestly contagious. 

Symptoms. — Hard swelling of one or both parotids — the swelling increasing 
till the fourth day, and then declining gradually. Skin over the tumor seldom 
red or inflamed ; the breasts in females and the testicles in males often swell 
about the period of the declension of the parotid tumefaction ; a sudden me- 
tastasis often takes place from the parotids to these parts. Fever generally 
mild, sometimes violent. Children and young persons are most subject to this 
disease, It is most common in cold and damp weather. 

Causes. — An epidemic influence, or perhaps contagion. It resembles conta- 
gious diseases, certainly in there being an immunity against a second attack. 

Diagnosis. — Differs from ordinary inflammation of the parotid in the greater 
rapidity of swelling, the tendency ti spontaneous subsidence, the difficulty of 
mastication, and the peculiar painfulness in masticating sweet substances — in a 
more general constitutional disturbance, its disposition to metastasis, and its 
usually prevailing epidemically. 

Prognosis. — Not in general a dangerous affection ; becomes more or less 
dangerous by being translated to other parts — as the genital organs, the lungs, 
the brain, the stomach. 

I have known a case terminate fatally in less than an hour, by metastasis to 
the brain ; when transferred to the testicles they occasionally suppurate — an 
occurrence always exceedingly painful, and sometimes fatal. 



American Medicine and Surgery. 303 

Treatment. — There-is but little danger, and very simple treatment is required. 
A gentle purgative with some warm tea, or the following will suffice : 

|k— Fid. Ext. Asclepias a . . . ) aa. 

" " Serpentaria ) 3 ss. 

Dose. — Twenty drops every three hours. Apply tepid water to the throat, or 
bathe the throat with : 

Jfi— Tr. Capsicum ) aa. 

'• Bellado na v 

" Arnica ) 3 i. 

Where the swelling disappears from the neck and attacks the testicles or 
mamma, we should adopt some active alterative course With warm applications 
to the neck and the discutient ointment to the affected parts. When the mam- 
ma or testes are involved, the following will be found to give almost immediate 
relief : 

#— Tr. Lobelia 1 QQ 

" Belladonna ' aa " 

" Aconite Fol : * , 

" Glycerine J 01, 

Apply a flannel saturated with the above, 



DYSPHAGIA. 



Difficulty of swallowing exists in several varieties. It sometimes occurs from 
nervous irritation, especially in young'women of irritable, nervous temperament, 
who suffer from weakness, or diseases peculiar to the sex. In these cases it is 
purely nervous, no emaciation, no pain, the attack comes from nervous excite- 
ment alone. Difficulty of swallowing may occur from spasmodic constriction 
of the pharynx, seldom met with, however. We also have it from mechanical 
injury of oesophagus, and is usually brought about by swallowing hard sub- 
stances, or imperfectly masticating food. Difficulty of swallowing, by produc- 
ing congestion, will sometimes produce apoplexy. 

Treatment. — Our best remedies are relaxants. I have often relieved with a 
teaspoonful of lobelia. The following is also excellent : 

#— Tr . Chinchona Comp 3 iv. 

" Nux Vomica 5 ss. 

Phosphoric Acid Dil Si. 

Glycerine 3 lii. 

Mix, and give one teaspoonful every three hours, or three times a day. 
Should it proceed solely from nervousness, in females, the cause must be re- 
moved, and then give : 

#— Fid. Ext. Cimicif uga 1 a i 

" " Cypripedium I ' 

" " Scutellaria ] 3 ii. 

Tr . Capsicum J 

Syr. Simplex 3 vni 

Dose. — One teaspoonful before each meal, 



304 Principles and Practice of 



ACUTE GASTRITIS. 

Anxiety, heat and pain in the epigastrium, increased by taking any thing into 
the stomach, an inclination to vomit, and immediate rejection of the injesta, 
hiccup, 

Symptoms. — Burning, pricking lancinating pain in the stomach, nausea and 
vomiting, extreme soreness with pain on pressure, tenderness, constant desire 
for cold drinks which are instantly vomited up. The tongue is generally red at 
tip and edges, covered in centre with white or yellowish fur. Patient lies with 
limbs drawn up, as in this position the muscles are relaxed. We have great 
depression, prostration, constipation, and scanty, high-colored urine ; pulse 
small and wiry ; intolerance of food or warm drinks. 

Causes. — Acrid or indigestible substances taken into the stomach, such as 
poison, caustic alkalies, arsenic, mercury, tartar emetic and other irritants; alter- 
nations of temperature ; draught of cold water while the body is hot ; suddenly 
repelled eruptions and metastasis, especially of gout. 

Diagnosis. — From spasm by the pyrexial symptoms and burning heat ; from 
enteritis by the seat of the pain ; by the burning sensation, vomiting and ten- 
dency to hiccup, even before the gangrenous termination, which in enteritis is a 
mark of gangrene having commenced. 

Prognosis. — If in the course of two or three days, the pain and sickness 
cease, while the pulse becomes more free and full, and diminishes in frequency, 
the urine depositing a sediment, and the bowels becoming spontaneously loose, 
a favorable termination may be expected. The unfavorable symptoms are a 
continuance of disease for several days, the pulse increasing in frequency, and 
hiccup remaining in spite of the medicinal process. 

Treatment. — The intense thirst is one of the most persistent symptoms to 
allay this, keep cold cloths over the stomach, and give : 

I*— Tr. Lobelia j aa. 

Fid. Ext. Asclepias \ ss. 

Dose. — Thirty drops every hour in the smallest possible quantity of water — 
gum arabic or slippery elm water is best. Give an injection of cold beef tea 
three times a day. Apply a warm flax-seed poultice sprinkled with pulverized 
capsicum, over the stomach, renewing at intervals. Sponge with soda dissolved 
in water, every three hours. Rub well in over the stomach : 



J^fc—Tr. Belladonna ") aa. 

" Hyosciamus 

Glyceri ;e 



• 1 aa. 



Continue this treatment until the irritation or inflammation is controlled, then 
establish convalescence on white of egg and milk, arrow root, etc. When the 
vomiting is persistent give, say, mucilage of elm with loaf sugar and a few drops 
of lemon juice. If there is delirium, or other urgent symptoms, give fld. ext. 
scutillaria and Pulsatilla equal parts, and give in thirty drop doses, in a table- 
spoonful of slippery elm tea. 



American Medicine and Surgery. 305. 



CHRONIC GASTRITIS. 

Chronic inflammation of the mucous membrane of the stomach, is of much 
more frequent occurrence than is generally supposed. The worst forms of dys- 
pepsia, and all that host of inveterate gastric and bilious derangements of 
which so much is heard, and the true nature of which is so often misunder- 
stood, are, in nine cases out of ten, the consequence of a more or less inflamed 
condition of the mucous membrane of the stomach. 

Symptoms. — A pricking, lancinating, or burning pain in the epigastric or 
hypochondriac region ; the pain is constant and harassing, generally confined' 
to a very circumscribed spot, and often attended with a feeling of constriction • 
sometimes a sensation is felt as if a ball were pressing on the diaphragm; at 
others as if a bar were fixed across the stomach impeding deglutition ; depraved! 
and impaired appetite, often general abhorrence of food ; indigestion, vomiting 
or nausea, load at the stomach after eating ; pulse but little excited and heat of 
the surface natural, except during digestion, when they are a little elevated; 
great costiveness during first period, but mucous diarrhoea after the disease has- 
become inveterate; the patient becomes irritable, dejected, taciturn, discontent- 
ed, tongue of the color of logwood, with a strip of thin fur along its centre. 
In inveterate cases, emaciation with the skin drawn tight over the muscles, so 
that it cannot be pinched up. The tightness of the skin is the most constant 
diagnostic sign of the disease. Mere gastric debility may be distinguished from' 
it by the effects of an emetic ; when fever, pain and anorexia become increased 
after the operation of an emetic, we may be sure of the existence of high irri- 
tation or inflammation in the mucous membrane of the stomach. 

Causes. — Indigestible and irritating diet, acrid medicines received into the 
stomach ; the abuse of spirituous liquors ; exposure to a cold and damp atmos- 
phere ; frequently the consequence of acute gastritis. 
Treatment. — We would give : 

Jjfc— Fid. Ext. Nux Vomica 5 iL ■ 

" " Dioscorej, ") aa. 



" " Cinchona J 3 ss. 

Dose. — Twenty- five drops in water half an hour after meals. 

fy— Sulp. Hydrastia grs. xxx; 

Aqua Calcis 3 xvi. 

* Dose. — One teaspoonful before each meal. 

Inflammation of the stomach, also, may lead to ulceration, and its train of 
evils. 

Ulceration of the stomach is usually seated at the posterior surface, or lesser 
curvature or pyloric pouch, generally round or oval shaped. A fatal termina- 
tion may result from hemorrhage, perforation, or exhaustion. 

20 



306 Principles and Practice of 



ULCERATION OF THE STOMACH. 

This generally begins with obstinate vomiting, showing either congestion or 
inflammation of the stomach. The vomiting may recur almost daily for 
months after inflammation has subsided. It is divided into three varieties : 
Superficial ulceration, follicular ulceration, and chronic or perforating ulcer. 
This distinction is made out post mortem, the symptoms of ulceration being 
rather obscure. 

Pathology.— : Ulcer of the stomach may originate in various ways ; and when 
it terminates fatally it is usually by perforation of the stomach. When this 
happens there are violent paroxysms, attended with unusual pain in the abdbmen, 
ending in collapse and death. The abdomen is found distended with air, and 
fluid similar to that vomited ; the coats of the stomach greatly thickened, espe- 
cially the parts near the ulcer. 

Symptoms. — An important symptom is pain, epigastric or dorsal, increased 
by pressure. This may occur with ulcer, but not necessarily a positive symp- 
tom. It may be an indication of an inflammatory condition of the stomach. 
To be positive of the existence of ulcer, the numerous symptoms must be well 
marked. The pain is accompanied with vomiting and hemorrhage at some 
stage of the malady in nearly all cases. If a case of sudden profuse gastric 
hemorrhage, we have to take into consideration the probabilities of it being 
associated with scirrhosis of the liver, vicarious menstruation, purpura, or dis- 
ease of the heart. If it cannot be attributed to any of these, and we have the 
epigastric and dorsal, we have strong reasons to suspect ulceration. It is true, 
we often meet with cases of gastric hemorrhage, complicated with depressed 
nerve-power and malarial disease apart from a special gastric affection. The 
gastric mucous membrane may suffer from hemorrhage by paralysis of the 
arterial nerves. 

Treatment. — In the greatest number of cases the same treatment should be 
adopted as for chronic gastritis. The irritating plaster should be applied over 
the stomach and removed every other day, free suppuration is desirable. 

J*— Fid. Ext. Leptandiin ) aa. 

" '• Myrica .'. > 

" " Geranium ) 5 ss. 

Dose. — Ten drops in mucilage of slippery elm, three or four times a day. To 
relieve pain, check irritation and support the strength, give : 

ffc— Fid . Ext. Papaver 5 i. 

Tr. Nux Vomica 5 ss, 

Dose.. — Ten drops once in two hours. 

This will bring up the nervous system, check the expenditure of tissue gen- 
erally. I have found small doses of sulphate of hydrastia — say, one-half 
grain, once in four hours — effectual in promoting healing ; so, also, the occa- 
sional use of the syrup of iodide ferri. If there is diarrhoea, give geranium and 
myrica ; if there is hemorrhage, large doses of myrica ; if there are eructations 
of air, regurgitations of food, inflammation of the mucous membrane, vomiting 



American Medicine and Surgery. .307 

of sour fluid, lime-water in milk answers well. The pain would always seem 
to be relieved by papaver and nux vomica. The secret of success is rest, per- 
fect rest, in the recumbent posture — this is essential. 

The diet should be bland, farinaceous, pulpy, given in small quantities, at 
short intervals, so as to avoid distending the stomach. If the stomach rejects 
every thing, suspend all nourishment for a time and give nutritious enemas. 

Our chief object in treatment must be to improve the general condition of 
the system, by nutritious food, giving remedies calculated to improve the general 
mucous surface and invigorate the organ as much as possible. 



DYSPEPSIA. 



The varieties of dyspepsia include all morbid conditions of the stomach, such 
as irritations of all kinds, chronic gastritis, and different forms of gastric de- 
pression or debility. The name, instead of expressing any particular patholog- 
ical state, has reference merely to a result which may proceed from different 
conditions of the stomach. 

Pathology. — The stomach in dyspepsia is in a state of comparative inactivity, 
being less of the solvent secreted, and less muscular movement to favor solution. 

Food remains in the stomach longer undissolved, and sometimes is not dis- 
solved at all. The gastric secretion is altered in quality, becoming acrid and ir- 
ritating, producing vascular irritation of the mucous membrane, and often a 
sympathetic nervous irritation of the muscular coat. Hence the heartburn, 
gastralgia and spasm, and frequently the vomiting and headache of dyspepsia. 
It is probably from defective innervation that the peculiar epigastric uneasiness 
arises. 

Symptoms. — One of the most prominent symptoms is a feeling of vague un- 
easiness in the epigastrium, not amounting to pain, but is often vvorse. This 
feeling is diffused over the epigastric region, and often extends to the hypochon- 
driac, chest and left side, and even to the shoulder and down the arms. The 
uneasiness is greatest when the stomach is empty, and is often replaced after 
eating by a sense of fullness or weight. 

Not unfrequently, along with debility of the stomach, there is an increase 
of sensibility, so much so that substances swallowed will occasion 
acute pain, and tenderness of the epigastrium on pressure. The appetite is 
usually more or less impaired ; sometimes craving or perverted. The patient 
commonly experiences a sensation of hollowness or s nking at the epigastrium 
when the stomach is empty. Thirst is not unfrequent. Regurgitation of food, 
or of a sour, bitter, acrid liquid. 

Eructations of wind are common symptoms. Among other disordered sen- 
sations, having their seat elsewhere, dependent upon, or produced by an ex- 
tended operation of the same cause, are headache, giddiness, heaviness of the 
head, pains between the shoulders in the back, irritability of temper, fretful- 
ness, etc. A tendency to low spirits, indisposition to exertion, dyspnasa, palpita- 
tions, short, dry cough, are not unfrequent symptoms. The patient sleeps 



308 Principles and Practice of 

badly, awakes unrefreshed, an depressed in mind, sometimes a morbid ten- 
dency to drowsiness. The tongue is usually furred, especially in the mornings. 
The bowels are usually constipated, unless complicated with chronic enteritis 
or excessive secretion of bile. 

The urine is variously affected, sometimes scanty and high colored, in others 
copious and limpid and almost colorless. The patient usually loses flesh, 
sometimes becomes much emaciated with flabby muscles, sunken abdomen, a 
pale, sallow skin, with an anxious expression of countenance. 

Causes. — The influence of sedentary habits, and errors of diet, are probably 
the most prolific sources of dyspepsia. 

Exercise, to a certain degree, is necessary to the support and vigor of every 
part of the body. The stomach, consequently, participates in the debility 
which results from the want of it. The gastric energies are impaired. The 
quantity and quality of the food taken are those adapted to undiminished 
powers of digestion. Hence it results that the weakest stomach is stimulated 
into undue exertion, and subsequently falls into a proportionate degree of lan- 
guor. This ends at length in a morbid gastric depression, constituting dyspep- 
sia. The habitual use of food difficult of digestion has the same effect in a 
healthy stomach. 

Larger quantities of food than the stomach can well manage, food insuffi- 
ciently masticated, the excessive use of alcoholic liquors, opium, strong coffee 
and tea, tDbacco, and especially the depressing emotions — grief, anxiety and 
fear. 

Treatment. — In the treatment of every form of dyspepsia, the diet should 
be regulated and easily digested. Nutritious food is demanded. New bread, 
tough or salted meats, alcoholic or fermented liquors, over-exertiort, nervous 
exhaustion, should be carefully avoided. We may improve digestion by rest, 
early hours, relaxation and change, salt water bathing, cold sponging, horse- 
back riding, etc. Our remedial agents, and they never fail in my hands, are the 
syrup hypophosphites before each meal. Half hour after meals give : 



fy— Tr. Nux Vomica Comp ) aa. 

" Sanguinaria > 

Fid. Ext. Dioscorea ) 3 ss. 



Mix. — Dose. — Twenty drops in water. At night give : 

ty— Fid. Ext. Populus Trem \ aa. 

" " Humulus j 5 ss. 

Dose. — Twenty-five drops before retiring. In taking meals, eat slowly, mas- 
ticate well and rest at least one hour after eating. 
We may alternate with : 

fy— Tr. Cinchona Comp g viii. 

Acid Phos. Dii 3 ii 

Syrup Simplex 3 vi. 

Dose. — One teaspoonful before each meal. After meals : 



Jtjtr — Fid. Ext. Eupatorium Pur. 



.1 

Dose. — Twenty drops in water 



aa. 



Xanthoxylum. 

Sanguinaria f ,. 

Helonias Dio j s ss. 



American Medicine a?id Surgery. 309 

Some mild laxative at night. Keep the bowels regulated with neutralizing 
mixture and leptandrin. No drastric purgatives but mild relaxants. 



CANCER OF THE STOMACH. 

The stomach may suffer from schirrus, medullary, or colloid cancer ; the af- 
fection is generally primary. 

The pyloric aperture is the most frequently attacked, next the cardiac orifice, 
and then the space along the smaller curvature. Sometimes the cancer, at the 
time of death, is of small extent, but occasionally, and especially in the colloid 
cancer, the disease spreads until the greater portion, or even the whole of the 
stomach, is involved. When the disease causes obstruction, narrowing of the 
pyloric orifice, the stomach generally becomes greatly dilated. Gastric cancer 
is more common in men than in women, and is rare before the age of forty. 
Very few cases survive two years from the first appearance of the symptoms. 
In schirrous, the most common variety of gastric cancer, life may rarely be pro- 
longed for three years, while in encephaloid and colloid, death often takes place 
within twelve months. 

Symptoms. — These will vary with the situation of the disease ; when it is in 
or near the cardiac orifice there will be merely pain and some difficulty in pass- 
ing food into the stomach ; if in the pylorus, pain and sickness, when a few 
hours after eating — digestion being completed — the chyme has to pass into the 
duodenum ; while, when the lesser curvature is the seat of the affection, the suf- 
fering will be often slight. 

Speaking generally, the principal symptoms may be described thus : pain in 
the epigastrium of a burning, lancinating or gnawing character, augmented 
after eating, and often increased by pressure, pain, anterior and posterior eruc- 
tations of fetid 'air, frequent nausea and vomiting, at first of ingesta and glairy 
mucous, subsequently of a bloody, sanious fluid, and sometimes of dark gru- 
mous matter, having a coffee ground appearance ; constipation and extreme and 
increasing emaciation and debility. 

Occasionally a pulsating tumor is felt in the epigastrium when the cancerous 
mass lies over the aorta ; or a tumor may be detected in some part of the epi- 
gastric, umbilical, hypochondriac regions, so placed as not to receive any im- 
pulse from the aorta. And then, in almost all cases, the countenance will pre- 
sent a peculiar cachectic hue and expression so characteristic of the cancerous 
diathesis. In malignant, as well as in simple ulceration of the stomach, perfo- 
ration may take place, with escape of the contents of this viscus — fortunately 
not always in the peritoneum. Communications are this way sometimes formed 
between the stomach and the outside of the abdomen, or between the stomach 
and duodenum, or even between the stomach and pleural cavities, lungs or per- 
icardium. 

Gastrocolic fistulas are much more common than gastro duodenal, while they 
have generally for their cause malignant rather than simple ulceration. In 
gastrocolic fistula moreover, the stomach and colon are not always found closeiy 



310 Principles and Practice of 

adherent ; but a cavity may intervene, as if a mass of cancerous or tuberculous 
matter had connected the two; and had been gradually hollowed out. The 
symptoms produced by such a fistula are chiefly fcecal, vomiting and the expul- 
sion of undigested food with the stools, owing of course to the passage of the 
contents of the colon into the stomach, and of the gastric matters directly into 
the large intestines. When these effects follow upon the symptoms of malig- 
nant or simple gastric ulcer, the diagnosis cannot be a matter of much difficulty. 
In the treatment of cancer of the stomach, we should pursue the same general 
course as laid down under the head of cancer. 



ACUTE ENTERITIS. 

This is an inflammation of the small intestine, and varies in its intensity. 
With active treatment resolution is soon effected. We are at a loss to deter- 
mine in enteritis just where the inflammation is located ; it may extend to all the 
coats i_f the bowels, or to only one. There is no mark, no manifest symptoms 
that enable us to say whether the duodenum, jejunum, or illium are affected. 

Symptoms. — Fixed, burning pain in the abdomen about the umbilical region ; 
obstinate constipation, nausea and vomiting, the latter being sometimes so se- 
vere as to communicate inverted action to the intestines, and produce stercora- 
cious discharges by the mouth ; fever with a small, frequent, and tense pulse ; 
very rarely, the pulse is full and hard ; dry and red tongue, urgent thirst, dry 
and hot skin, urine high colored and small in quantity ; respiration short and 
performed by the intercostals exclusively ; position on the back, with knees and 
shoulders elevated. \ 

When the upper part of the colon is affected, acute enteritis is often attended 
by symptoms of pleuritic or hepatic inflammations. 

Causes. — Atmospherical vicissitudes ; exposure of part of the body to cold ; 
getting wet in the feet, spasms of the bowels, and strangulated hernia. Very 
often inflammation is actually induced by a constipated bowel ; sometimes this 
is only a predisposing and assisting cause. 

Diagnosis. — From colic by the presence of pyrexia and the increase of pain 
upon pressure, from gall-stones, from nephritis, from gastritis. 

Prognosis. — The constipation giving way, the pulse becoming fuller and less 
frequent, the pain changing its seat, the abdomen becoming less tender and 
tense, equal, warm and free perspiration, with sediment in the urine, are favor- 
able tokens. The unfavorable ones are rigors, which are not very common in 
enteritis; sudden cessation of pain, while the pulse increases in frequency: 
hiccup ; cold extremities ; clammy and partial perspiration, and an increased 
tension of the abdomen. 

Treatment. — This should be directed to equalize the circulation, and with 
this end in view I would prescribe : 



P— Fid. Ext. Serpentaria. 
" " Cimicifuga , 



) aa. 

) 3 ss. 



American Medicine and Surgery. 31 1 

Mix. — Dose. — Half a teaspoonful every two hours. To relieve pain, we 
would give : 

H— Fid. Ext. Lactuca . . . . ) aa. 

" " Humulus ) g ss. 

Dose. — Twenty to thirty drops every three hours until relieved. Over the 
bowels we would advise the application of warm poultices of slippery elm or 
linseed, sprinkled with capsicum — change as often as cold. This is one of the 
best means of restoring the vital powers to the intestines. 

After the urgent symptoms have passed, we would give : 

JEjfc.— Tr. Cinchona Comp g iv. 

" Nux Vomica g ss. 

" Hydrastis Can g 1. 

" Sanguinaria '. • ss. 

Mix. — Dose. — Forty drops in sugar and water every four hours. As a drink 
give sweet milk three parts, lime water one. Mix, and take as freely as the 
thirst demands. 

Establish convalescence on a good tonic, keep the patient quiet and for sev- 
eral days confined to bed. 

Rest is all important, and to that end we would give the lactuca and humulus 
freely as long as there is pain. 



CHRONIC ENTERITIS. 

This modification of enteric imflammation is of frequent occurrence. Its 
symptoms are oftsn obscure and equivocal. Most of the cases usually termed 
marasmus, consist of chronic inflammation of the mucous membrane of the 
bowels. Chronic diarrhoea also generally depends on this grade of internal 
inflammation. 

Symptoms. — No distinct abdominal pain, obtuse pain or firm pressure on the 
abdominal parietes ; a sense of soreness also is felt ; muscular debility, pulse 
small and weak, cold hands and feet, slight febrile exacerbations in the evening 
pain in the bowels, or nausea after taking food, frequently constant diarrhoea ; 
in inveterate cases the skin is dry and sallow, sleep interrupted, tongue smooth 
and red round the edges and brown in the middle, great emaciation, painful 
diarrhoea, alterrating also with costiveness, appetite variable, being sometimes 
voracious, at others entirely gone ; the food is often evacuated from the bowels 
in an imperfectly digested state ; the alvine evacuations vary in appearance, 
sometimes slimy and small in quantity, at others copious, liquid and dark. The 
disease continues for many months and even for several years. 

Causes. — Sometimes the consequence of acute inflammation of the mucous 
membrane of the bowels, irritating and indigestible food, the influence of a 
cold and damp atmosphere, drastic cathartics and other irritating substances 
whether received from without or generated in the bowels. 

Treatment. — Chronic enteritis should be treated similar to chronic dysentery, 
the two are often so intimately connected that the plan of treatment laid down 
under that head will apply to chronic enteritis. 



312 Principles and Practice of 

The diet should be light and nutritious, the quantity regulated to suit the re- 
quirements of the case ; thorough hygiene, perfect rest, salt water bathing, 
country air; the mind free from care and avoidance of all stimulating, irrita- 
ting substances, either as a diet or medicine. This, with treatment laid down 
under head of dysentery, will succeed in every case where the vital power has 
not run too low. 



INFLAMMATION OF THE C^CUM. 

The caecum, or its appendix, situated in the right iliac fossa and covered by the 
peritoneum — anteriorly'and latterly — may be seriously diseased without any other 
part of the intestines being affected. Thus, severe colic, and even fatal ileitis, 
may arise from the lodgement in this part of the alimentary canal of hard faecal 
matter, skin or stones of fruit, biliary and intestinal concretions, balls of lum- 
brici and ascarides, etc. 

Sometimes the intestinal matters accumulate to such an extent as to produce 
a large tumor, and many are the cases where the patients have recovered upon 
passing an immense quantity of faeces, after a careless practitioner has diag- 
nosed abscess or cancer of the kidney. 

When any of the morbid matters get impacted in the vermiform- appendix of 
the caecum, dangerous inflammation, ending in abscess, is very likely to arise* 
while, as we shall presently see, the persistence of disease in the appendix may 
form the starting point of the morbid process in the caecum itself. The inflam- 
matory process may affect only the vascular surface, or all the coats of the 
caecum ; in either case, the affection being termed ccecitis or typhlitis, or typho- 
enteritis. So we may merely have inflammation of the appendix c@ci, which 
is attended with more acute symptoms than simple typhlitis, or the abundant 
areola tissue, which connects the caecum to the psoas and iliac muscles may be 
especially involved, and then perityphlitis is the rather pedantic name applied 
to the disorder. 

Whether it be true or not that an important part of the process of the diges- 
tion is carried on in the caecum, it cannot be denied that irritation, and perhaps, 
the suspension of the functions of this part by disease, soon gives rise to prom- 
inent symptoms. Thus, there is always more or less general constitutional dis- 
turbance, slight fever, nausea, and often constipation, together with fulness and 
tenderness in the right iliac region, the pain being rendered exquisite by pres- 
sure upon the caecum or the parts in its immediate vicinity. The patient lies 
on his right side, with the trunk bent and the knees drawn up, so as to relax the 
tissues about the seat of inflammation. The pulse is not quickened to the same 
extent nor is the countenance as anxious as in peritonitis or enteritis. Suppos- 
ing the disease to progress, the peritoneal surface of the caecum becomes in- 
volved, the appendix gets inflamed, and we soon have evidence of the existence 
of general peritonitis while the arolar tissue may also be affected, and suppura- 
tion and abscess result. 

The latter may be open externally, or into the intestinal canal, and the patient 



American Medicine and Surgery. 313 

recover, but sometimes the matter is discharged into the cavity of the periton- 
eum, causing great suffering, and in a few hours death. 

If the inflammation begins in the appendix from constitutional causes, or owing 
to the escape into this part of morbid matters, the symptoms are generally 
very acute, consisting especially of excruciating tormina, violent sickness, pain 
in right testicle and thigh, and obstruction of the bowels. Gangrene of the af- 
fected part, with general peritonitis, frequently ensue and prove fatal. In tuber- 
culous typhlitis ulceration occurs more frequently in the appendix than in the 
caecum itself. The early symptoms of peretyphlitis are severe pains shooting 
from the right iliac region diarrhoea and tenesmus, nausea, fever, etc. The 
parts around the seat of inflammation become swollen and unless resolu- 
tion takes place, suppuration occurs. Frequently the abscess opens into the 
cavity of the caecum, and with care the patient recovers. 

Occasionally the physician meets with cases of chronic inflammation of the 
caecum, in which the symptoms come on very slowly, with failing health, weak- 
ness and loss of flesh, colicky pains in the right iliac region, flatulence, and 
anorexia, and alternately diarrhoea with constipation. Frequently the mucous 
coat of the bowels ulcerates; and then there are numerous mucous discharges, with 
attacks of hemorrhage, the loss of blood at times being considerable. If there 
be much thickening of the walls of the caecum and tumefication, the case might 
be mistaken for an aneurism of the iliac artery. If death occur it is generally 
from exhaustion, while at the autopsy the intestinal coats are found consider- 
ably thickened, inflamed and ulcerated. Very rarely is there perforation. 

Treatment. — The treatment of all affectfons of the caecum requires con- 
siderable caution. Generally speaking, anodyne fomentations or poultices will 
require to be assiduously applied while lactuca is given internally. This latter 
remedy must be used so as to keep the patient free from pain, and its influence 
should be maintained for several days. Effervescing drinks, lemonade, and ice, 
will be useful in relieving the nausea, while if it appear necessary to obtain an 
action from the bowels, sweet oil enemata may be employed. In chronic cases 
I have seen most good from simple nourishing food, warm bathing, sedative 
linements used night and morning, and the employment of small doses of 
nitro-muriatic acid and cinchona. If an abscess points externally, it should be 
opened. 



CONSTIPATION. 



In ordinary good health, the intestinal apparatus completes its revolution 
once in twenty-four hours. In other words, once in twenty-four hours the pro- 
cess of mastication, digestion, nutrition, absorption, and the carrying forward 
for an expulsion of the faeces should be accomplished. Any deviation from 
this, is a deviation from a natural or healthy standard, and will eventually result 
in a constitutional derangement or diseased condition. 

Constipation is a morbid condition or derangement affecting a part or the 
whole apparatus. Although it may not appear to give any inconvenience at the 



314 Principles and Practice of 

time, it will eventually cause trouble. There is a condition of gastro intestinal 
torpor, but no structural disease. The natural peristaltic action of the bowels 
is deranged, either from a deficiency of bile or healthy secretions from the liver, 
or torpidity of that organ. 

A deficiency of bile, constitutes a prominent difficulty in constipation. We 
have deficiency of vitality of the nervous system, and hence we often find it an 
attendant upon scrofula, anaemia, chlorosis, general nervous debility, etc. 
Constipation, like all other derangements of healthy functions, if not relieved, 
progresses from bad to worse. The retention of effete matter in the bowels is 
a source of discomfort, to say the least. It impedes the progress of assimila- 
tion, the food does not perform its proper function ; so we have growth and 
nutrition arrested, and consequently lack of nervous energy and muscular 
power. 

Treatment. — The treatment of constipation by purgatives, is irrational and 
unscientific, and the victims of habitual constipation have come to feel there is 
no cure for them — only temporary relief. 

To make a success in our treatment, we must know the cause upon which it 
depends, and set about removing that. To cure constipation, we do not need 
purgatives ; they do more harm than good. We must give tone and strength 
to the* nerves and biliary functions, and improve the secreting powers of the in- 
testines. Habit has a wonderful effect on constipation, The habit of relieving 
the bowels at a particular time every day — say after the morning meal. In many 
cases, scrupulous attention to this will soon overcome the constipation. The 
act of eating gives an impulse to the peristaltic action, and consequently an 
action is much easier at this time. Moderation in every thing, daily bathing, 
exercise, friction to the whole body, especially the spine. Water internally is a 
valuable agent, drinking water freely, just before retiring at night, and first 
thing of a morning, has a beneficial effect, not only in this, but in other diseases 
of arrested nutrition, etc. Habitual constipation and want of secretion may be 
promptly relieved by the following : 

JE-fc— Fid. Ext. Leptandrin ) aa. 

Tr. Nux Vomica j S ss. 

Mix. — Dose. — Twenty drops in water at bedtime. Give fifteen drops dilute 
nitro-muriatic acid in a wineglass of water before each meal. If this fails give : 

JEjfc— Pul . Oxgalls grs . x . 

Ext. Nux Vomica grs. ss. 

Mix, and give night and morning. 

I have found in some cases electricity acts well. Apply the positive pole to 
the spine, and the negative to the bowels, or apply the positive to the tongue, 
and the negative to the rectum. Wholesome and digestible food, ripe fruit, 
light bread, daily exercise, avoid too much sleep. 

I have found a tonic bitters composed of the following, acts well : 



Jtjfc— Hydrastis Can. 



) aa. 
jTiT 



Helonias Dioi 

Sanguinaria 5 ss. 



American Medicine and Surgery. 315 

Steep in a quart of good spirits, and take a tablespoonful before each meal' 
As we are creatures of habit, many of the ills and shortcomings of life may 
be traced to that, and we have really very few cases of habitual constipation 
that can not be traced to something of this. kind; and, as habit produces the 
derangement, so will habit, with a little assistance to nature, correct it. 



INFLAMMATORY DYSENTERY. 

This is an affection or inflammation of the alimentary canal, attended with 
fever, fetid or bloody evacuations, and appears to be-contagious. It is often as 
intractable as Asiatic cholera — prevails in both city and country. It may be in 
isolated cases, but usually attacks great numbers in one place, while adjacent 
towns are free from it. In some instances the inhabitants of the most healthy 
country towns are attacked with it and die off in great numbers. If not speed- 
ily overcome after it appears it assumes the form of bloody dysentery, and be- 
comes highly dangerous. It prevails throughout the year, but with greater vio- 
lence during the months of July, August and September. 

Pathology. — Dysentery of the form now under consideration, is evidently an 
inflammation of the mucous tissue of the primas vise, particularly of the large 
intestines. So long as it is confined to the mucous tissue there is prostration 
of strength, and discharge of mucus, variously colored, or otherwise changed, 
with little or no pain. Extending to the muscular coat, tormina and tenesmus 
are induced, and the darting, lancinating pain must be ascribed to an extension 
to the peritoneal coat. The skin being robbed of its fair proportion of excite- 
ment by the irritation of the interior becomes cold and collapsed until reaction 
takes place. Yet it finally relapses, when the case does not proceed well into 
its former condition. The sympathetic fever is sometimes intermittent, though 
often remittent or continued. 

Symptoms. — An attack in warm weather is usually introduced by anorexia, 
epigastric fullness, furred tongue, thirst, bitter taste, nausea and sometimes 
vomiting, uneasiness in the abdomen, dry skin, muscular soreness and debility, 
or it is introduced directly by a chill and fever. 

After the constitutional disturbance, follow griping and a propensity to go to 
stool ; large feculent or watery discharges for a time, then small ones, consisting 
of mucus only, or tinge J with blood ; a sense of weight or dragging in the 
lower part of the abdomen, and either fugitive pain or permanent tenderness- 
But often the local affection supervenes first, and the system may sympathize 
very little throughout the case — certainly not to the extent of a fever. In a still 
more advanced stage we have stools more frequent and painful, every evacua- 
tion being attended with an "aggravation of symptoms, violent straining, and a 
good deal of rumbling from flatulence. ' 

Occasional prolapsus of the intestine. The discharges sometimes become 
like cheese, or they may be purely hemorrhagic. Again, there may be evacuated 
a substance like flesh, composed of coagulated lymph, or impacted mucus red- 
dened with blood, or matter resembling the mucous coat of the bowels. 



316 Principles and Practice of 

» 

The scybalas which are in some instances discharged, consist of hardened balls 

of fasces. Little or no bile is ever apparent in the stools. Although there be 
fever, the pulse is seldom full or active, however tense and corded it may be. 
In the final stage there is depression of strength, cold skin, sometimes petechias, 
great soreness and tension of the epigastrium, feeble pulse, a singularly altered 
and often corpse-like countenance. 

These symptoms may be varied by a concentration of the disease in a par- 
ticular section of the bowels, or a particular coat, or by the complication of 
other affections. 

Causes. — Miasmata, an excess of heat, sudden variations of temperature ; a 
damp, heavy, murky atmosphere ; a calcareous soil, epidemic influence and 
checked perspiration, by whatever cause produced. 

Cer ain ingesta, among which may be mentioned crude fruit, and unwhole- 
some vegetables, and particularly putrid or spoiled aliment. A sudden change 
from an animal to vegetable diet, or the reverse ; or from salted to fresh provi- 
sions, or the opposite. Acid beverages, stagnant water. 

Diagnosis. — The only disease with which dysentery is liable to be confounded 
is diarrhoea, and here the treatment is so similar that the discrimination is un- 
important. 

Prognosis. — Cases in which the stools consist almost entirely of blood, are 
generally more tractable than when the discharges are principally mucous. 
Colliquative diarrhoea, at an advanced period, very unfavorable ; stools of a 
penetrating and cadaverous smell, a very bad sign. Tympanitis, with small 
mucous stools, or with fetid sanious discharges from the bowels, highly un- 
favorable. A small, frequent pulse, with a sunken and cadaveroiiscountenance, 
hiccough, and cold extremities, indicate a fatal termination. Bile appearing in 
the stools is a favorable sign. 

Post Mortem. — Very similar to those already described as belonging to en- 
teritis. The lesions are chiefly seated in the mucous coat of the large intes- 
tines, and, above all, the colon. The other coats are comparatively little af- 
fected. In hot countries most of the abdominal viscera are apt to share in the 
disease. The liver is especially apt to be congested, and may be structurally 
affected. 

Treatment. — To meet these indications, when we have reason to suspect the 
stomach is loaded with irritating substances, we should give an emetic of the 
lobelia comp., follow with alcoholic vapor bath, and then give : 

Yfr— Epsom Salts ~) aa. 

Magnesia J q. s. 

Mix. — Give a tablespoonful once in three hours, until a mild purgative effect 
is had, then follow with : 

#— Syr. Rheiet Potass ' 5 iij. 

Fid. Ext. Geranium Mac Si. 

" " Asclepias ~| aa. 

" " Serpentaria J 5 ss. 

Dose. — One teaspoonful every two hours. 



American Medicine and Surgery. 317 

We may alternate with : 

#— Tr. Capsicum ~| aa. 

Fid. Ext. Populus ... . ., j 3 ss. 

Dose. — Twenty drops once in two hours. 

Locally we would apply some stimulating poultice or warm fomentations 
over the stomach and bowels. Dysentery is always attended with an arrest of 
the functions of the skin, and we should direct our efforts to bring about a ter- 
mination to the surface. The above plan of treatment will be found effectual in 
every case. The practice of giving opium astringent to dry up the secretion is 
founded on error and attended with poor success. When, we have great pain, 
cramping, etc., we may resort to the fid. ext. of humulus or lactuca to relieve 
urgent symptoms. * 



CONGESTIVE, OR TYPHOID DYSENTERY. 

Pathology. — The peculiarity evidently consists in there being, instead of an 
actively inflammatory state, a congestive condition, with a tendency to rapid 
disorganization. 

Symptoms. — The most prominent feature of this form is a want of reaction. 
The skin continues cold, dajrip and mottled, or, as may happen, partially dry 
and heated ; the tongue loaded and dark ; and there is much gastric, and occa- 
sionally some •cerebral disorder. Contracted under peculiar circumstances 
the disease has received a modification partaking of the nature of scurvy. To 
many of the symptoms already detailed, are here added soft, spongy, livid 
gums occasionally so ulcerated that the teeth become loose and fall out ; the 
lips and mouth are livid, and the breath foetid ; while, more or less, over the 
whole body, though particularly on the extremities, large blue or purple spots 
are dispersed. 

Causes. — The congestive species of the affection is principally met with in 
crowded, ill-ventilated places, as in ships, hospitals, prisons, besieged towns, 
and camps. The cause to which, when thus appearing, it is generally assigned, 
is contagion. The effluvium is by some supposed to spring immediately from 
the excrementitious discharges, while others suppose it to be the product of 
their putrifaction. There seems to be, however, no substantial demonstration 
of the truth of either of these theories. The probability is that typhoid dys- 
entery is the result of a contaminated atmosphere, acting at a time when there 
is a predisposition to dysenteric disease. 

Other causes are epidemic influences, and those causes already enumerated, 
as productive of the inflammatory variety. 

Prognosis. — Sometimes extremely intractable and fatal. 

Post Mortem, — Generally, in the place of the marks of active inflammation 
we meet with turgescency of the vessels of the intestines, with ecchymosis 
and softening of the mucous tissue, and perhaps gangrene of all the coats. 
Various other abdominal viscera are frequently involved, and sometimes the 
brain. 



3 18 Principles and Practice of 

Treatment. — A low collapsed state existing, the skin is to be excited by alco- 
holic vapor bath, stimulating friction, etc. 

Emetics are well suited to this form, even when the stomach is not loaded 
with irritating contents. 

Then follow with : 

fy— Tr. Capsicum ^ aa. 

Fid. Ext. Xanthoxylum V — 

" " Serpentaria ) 3 ss. 

Dose. — Thirty drops once in three hours. 

Also the sulphate of quinia, charcoal to correct the fcetor ; the nitric or nitro- 
muriatic acid in the scorbutic variety, warm applications over stomach and 
bowels. Other remedies may be used to meet the case. 

The diet, in the early stage should lie like that in the inflammatory form ; but 
when debility of the vital forces has supervened, to the farinacious articles may 
be added wine, milk punch, chicken, mutton, or beef tea. An intermittent is 
sometimes conjoined with dysentery. The best plan here is to neglect the 
former until the latter is reduced. The same principle holds in the complica- 
tion of dysentery with rheumatism, and some other diseases. But it is here 
supposed that the bowel affection is strictly inflammatory. In the low forms 
the quinine might be adapted to both complaints. 



DIARRHCEA. 



If the absorbing powers of the intestines are defective, the consequences are 
excess in the quantity of matter that passes through them. That which ought 
to be taken up is carried along, and constitutes a diarrhoea. It may depend on 
a variety of causes, as a relaxed condition of the bowels, improper diet, unripe 
fruit, hard, indigestible substances taken into the stomach. We may divide the 
disease according to the appearance of the discharge. We have several varie- 
ties, first of which is : ' 

FECULENT DIARRHCEA. 

This usually results from over-feeding in children, and over-eating in grown 
people. The prominent symptoms of this form of diarrhoea is looseness of the 
bowels, with or without griping pain ; frequent discharge of thin, watery matter, 
undigested food, usually of an acid nature. This condition is accompanied by 
partial or complete loss of appetite, pain in the stomach, swelling and tender- 
ness in the lower part of the abdomen. We may have nausea and vomiting, 
urine scanty, etc. The discharges are painful usually, though sometimes with- 
out pain. We^mayhave mucous or purulent discharge. 

Causes. — The cause of this form of diarrhoea is either dentition or worms, 
and is sometimes due to irritating food in the stomach. I will also mention 
sudden changes of temperature as among the causes. If the diarrhoea depends 
upon dentition, we must treat the case as directed under that head. 

Treatment. — Give the neutralizing cordial three or four times a day in tea- 



American Medicine and Surgery. 319 

spoonful dose. Give leptandrin in small dose, say one-half grain once a day. 
Salt water baths daily, with warmth to the spine and bowels. The diet is an 
important element, and should be carefully attended to. We must have some- 
thing to supply nutrition without taxing the digestive organs. Milk and lime- 
water is excellent, arrow root, corn starch with nutmeg, rice flour, Irish pota- 
toes, etc., are among the best articles. 

BILIOUS DIARRHCEA. 

This is the next simplest form of diarrhoea. We have a large amount of 
bile thrown off from the biliary ducts without corresponding absorption, and 
this of course adds largely to the amount of matter thrown off. This condi- 
tion may be brought about by cold, mental emotion, irritation, and from want 
of action in the secreting system. Persons of a bilious or phlegmatic tempera- 
ment, are more subject to it than any other class. In such patients we some- 
times have the bile deficient and then again poured out to excess. Irritation of 
the stomach or intestine that leads from the stomach, causes the bile to be re- 
tained in the liver and gall bladder until it is unfit for absorption. 

Symptoms.— Viz can always detect bilious diarrhoea by the peculiar odor and 
look of putrescence of undigested matter. If the discharge is mucous and 
mixed with blood, we recommend in the treatment, an occasional dose of one- 
half grain of podophyllin and twenty-five drops of dilute nitro-muriatic acid. 

SEROUS DIARRHCEA. 

Aqueous or watery discharges— profuse, constant, and exhausting. It comes 
from an excessive accumulation and want of absorption. In this form of di- 
arrhoea we have a sort of congestion of the vessels or veins that supply the in- 
testines. We have deficient vitality in the mucous membrane, and finally ulcer- 
ation of the bowels. 

Treatment.— In treating this form we must have an eye to the diet. Apply 
stimulating liniment to the bowels, keep the patient in bed, and we give in con^ 
, nection : 

#— Comp Tinct. Cinchona s . 

Nitro-muriatic Acid Dil '. ...".".....""".".'.".".*. .'.'.' \\- 

Mix and give thirty drops three or four times a day. Alternate with : 

#— Fid. Ext. Geranium Mac ... -, 

} aa 

" " Myrica Cer 



3ii. 



Zto*.— Twenty-five drops every two hours. Nux vomica acts well ; ten drops 
of the tincture three times a day. It acts as a nerve stimulant to the bowels, 
and is advisable where there is nervous depression and weakness. 

MUCO-PURULENT DIARRHCEA. 

In this form we have, in addition to the watery form, particles of mucus mix- 
ed with the stool, and a shred-like substance (fibre) and similar flake-like blood 
globules, the peculiar lining membrane of the bowels. The discharge partakes 
of an alkaline nature. 



320 Principles and Practice of 

Treatment. — We should treat with the nitro-murlatic acid and tonics, among 
which we shall find none act better than prunnis vir. The stools become putrid, 
and to correct that, we might give an occasional dose of prepared charcoal. 

CHRONIC DIARRHCEA. 

Either form of the above may produce chronic diarrhoea, if long neglected, 
and this is too well marked to need an extended description. I have rarely 
failed to cure chronic diarrhoea, and the following is my first prescription : 

J^-Fld. Ext. Populua Trem 1 

" " Prunnis Vir I aa. 

" " GeraniimMac !■ 

" " Myrica Cer | 3 i. 

" " Hamamelis I 

French Brandy ss. 

Syr. Simplex ss. 

Mix. — Dose. — One-half wine glass before each meal. 

#— Tr . Nux Vomica *} aa. 

" Sanguinaria > 

Fid. Ext. Dioscorea J 8 ss. 

Mix. — Dose. — Twenty-five drops after each meal. Bathe the bowels with 
some stimulating linement. Under this treatment, and a generous, nutritious 
diet, improvement is rapid. 



CHOLERA MORBUS. 

Frequent and violent discharges of bilious matter from the stomach and 
bowels, with painful gripings, constitute cholera morbus. In our climate it is 
met with in all seasons of the year, although it is more apt to prevail in the 
summer and autumn when there is excessive heat, or sudden transitions from 
heat to cold ; and the violence of the disease has usually been observed to be 
greater in proportion to the intensity of the heat. These and other circum- 
stances lead us naturally to conclude that cholera morbus is the effect of a 
warm atmosphere, producing some change on the eight pairs of nerves which' 
supply the liver and biliary duct, which change consists either in the matter of 
bile being rendered more acrid, or acid, or of its being secreted in a preternatural 
quantity. In some instances the disease can be clearly traced to obstructed 
perspiration, from food that has become acid upon the stomach, or has passed 
into the acetous fermentation, as unripe fruit, torpor of the liver, obstruction of 
the bile duct, predisposed to by nervous prostration. 

Symptoms. — It usually comes on with nausea, soreness, pain, flatulency in 
the stomach, acute griping pains in the bowels, succeeded by intense and fre- 
quent vom ting, and purging of bilious matter, heat, thirst, hurried respiration, 
and a frequent but weak and fluttering pulse. When the disease is not violent, 
these symptoms after continuing for a day or two, gradually cease, leaving the 
patient in a debilitated or exhausted condition ; but when the disease proceeds 
with great violence, there arises great depression of strength, cold, clammy 
sweats, considerable anxiety, a hurried and short respiration, cramps in the 



American Medicine and Surgery. 321 

legs, coldness of the extremities, and other symptoms of sinking, with an inter- 
mitting pulse, which quickly terminates in death. 

Diagnosis. — Cholera morbus is to be distinguished from diarrhoea and dys 
entry by the matter which is discharged being pure bile, unmixed with blood 
and mucous, and scarcely any fasces. It may de distinguished from colica 
pictonum by the evacuations ; for in the latter there is always a considerable 
quantity of bilious matter ejected by vomiting; still the bowels remain obstinately 
costive. 

Prognosis. — This must be unfavorable when the evacuations upwards and 
downwards are accompanied by great prostration of strength, tympanitic ab- 
domen, intermitting pulse, cold, clammy sweats, hurried respiration, hiccough, 
spasm of the extremities, or convulsions, but a gradual diminution of the symp- 
toms, especially vomiting, succeeded by sleep or a gentle moisture of the skin 
may be regarded in a favorable light. 

Treatment. — From the very irritable state of the stomach in the first attack 
of the disease, it is almost impossible for any kind of medicine to be retained 
on it — every thing being rejected the moment it is swallowed. To relieve this 
irritation, and evacuate the redundant acrid bile give an emetic of the comp. 
powder of lobelia and follow this with thirty grains of the bicarbonate of soda. 
After emesis ha^ been thorough, give : 

#— Fid. Ext. Xanthoxylum ) aa. 

" " Zingiber ■ ; V 

Tr. Capsicum ) 3 i. 

Dose. — Half teaspoonful in sugar and water, and repeat every fifteen min- 
utes until warmth is experienced and cramp is relieved. In addition to these 
means stimulating applications should be made over the region of the stomach, 
and indeed over the entire abdomen; first sinapisms, then fomentations. 
Warmth should also be applied to the extremities ; first the mustard foot-bath, 
then artificial heat. 

If prostration is extreme, wrap the patient up in a blanket saturated with 
mustard, and give stimulants. I have found the following also to be effectual : 



#— Syr. Rhei. et Potass ." ) aa, 

Tr. Xanthoxylum 

" Leptandria 



) aa. 
I Si-' 



Mix. — Dose. — Half a teaspoonful every twenty minutes till the patient is re- 
lieved. If this does not quickly succeed alternate with : 

Tfc— Tr. Capsicum I 

Ess. Peppermint r I \ 

Spt Camphor •• l*i 

Fid. Ext. Papaver . ...J 31, 

Syr. Simplex 3 iv. 

Dose. — One teaspoonful in water every half hour. The lungs and liver are- 
the great decarbonizing organs of the body. The lungs are most active in. 
cold weather, from the part they perform in generating animal heat. In sum- 
mer the liver is stimulated by the heat to increased action, and forms a large 
quantity of bile, which is required to perform important uses in the function' 
of digestion. In order to have a perfect state of health these organs must 
be in perfect harmony ; for if we have entire suppression of the function of 
21 



322 Principles and Practice of 

the liver, we immediately have extreme congestion of the liver, stomach and 
intestines. 

This condition always leads to increased sensibility and this leads to 
vomiting. The most efficacious remedies in the treatment, after arresting 
the vomiting, are small doses of capsicum. 

The latter agent may often be relied upon when the vomiting is extreme. 
In all cases astringents are contra indicated as they aggravate the complaint 
by retaining vitiated bile in the intestines, which ought to be discharged as 
png as the morbid secretion from the liver continues. As the debility is 
usually very great, it is proper, as soon as the intensity of the disease is 
allayed, to begin with tonics and nourishment. 

For this purpose, hydrastis, cinchona, etc., will answer well, and the 
diet nutritious, easily digested, such as beef tea, white of eggs, etc. 



CHOLERA INFANTUM. 

This disease of children is, perhaps, peculiar to the United States. 

The period of its greatest prevalence is between the ages of twelve and 
eighteen months. It mostly begins among us in July and continues till the 
accession of frost. It may, from its destructiveness, be called the scourge of 
children. Its popular name is the Summer Complaint. 

Pathology. — The disease in its most familiar presentation, is a gastro- enteric 
affection, soon involving the liver. The excitement of the stomach and intes- 
tines, being communicated to the liver, produces at first an increased flow of 
bile; but the liver being long subjected to this high action, becomes exhausted, 
and its secretory power suspended. But in other cases the inceptive impression 
is so strong that the secretion of bile is at once arrested. The brain, and sys- 
tem in general, become soon involved in the play of sympathies. 

Symptoms. — It may approach like a dysentery, though sometimes its com- 
mencement more nearly resembles a cholera morbus. Its most common and 
characteristic presentation, however, is that of gastro-enteritis, in every grada- 
tion of violence, from simple irritation to the most intense inflammation. Cere- 
bral effusion is sometimes early manifested in a tendency to delirium or stupor 
The fever, when confirmed, is of an irregular, remittent type. The desire foi 
drinks is now unquenchable. 

The evacuations are watery, or slimy or mucoid, or like coffee grounds, o; 
deep green, or of a colorless fluid, leaving a pink margin around the soiled por- 
tion of the napkin. 

They have usually <a sour or putrid odor. Great irritability of the alimentary 
canal existing, the ingesta pass off immediately. 

When the attack runs a lengthened course, few diseases exhibit more emaci 
ation, or greater alteration of condition and aspect. The alvine discharge 
sometimes at this period amount to forty or fifty in twenty-four hours. 

Towards death the face and belly may become bloated, the feet ©edematous 
and the mouth sprinkled with apthae. The mental faculties and senses are ap 



American Medicine and Surgery. 323 

to become extremely torpid. This protracted form of the disease may continue 
five or six weeks. 

Causes. — Exclusively incident to children, and almost so to those living in 
cities. Damp, murky weather is favorable to the origination of the disease. 
Exciting causes are improprieties in diet or clothing, teething, worms and pre- 
mature weaning. 

Diagnosis. — The affection may in general be easily recognized. 

Should it be confounded with diarrhoea, dysentery, or cholera morbus, it will 
probably, in such cases, be essentially the same with these diseases, and re- 
quire the same treatment. Even when mistaken for the common irritation of 
teething, the treatment is so analogous that nicety of discrimination is not re- 
quired. 

Prognosis. — A prognosis is very hazardous, since the most favorable looking 
cases are apt to terminate fatally, and vice versa. 

The chances, however, are vastly greater, other things being equal, when a 
free ventilation is commanded. The appearance of dark, bilious or natural 
stools is a most propitious sign". Among other unfavorable signs, too obvious 
in their character to be here mentioned, may be stated the purging of a pink 
colored fluid, or the fluid which leaves a pink stain around the soiled parts of 
the napkin. This is an almost certain indication of death. 

Post Mortem.— The brain in recent cases presents only slight venous conges- 
tion, or where cerebral excitement has existed, inflammation of the membranes. 
But in protracted cases effusions are often observable. In the alimentary canal, 
especially the upper part, we have the evidence of inflammation, often contor- 
tion and intussusceptions of the intestines. The peritoneum may exhibit a 
morbid appearance and effusion in its cavity. The liver, in cases of long con- 
tinuance, is in some instances so much hypertrophied as to occupy two-thirds of 
the abdominal cavity. On the contrary it has appeared atrophied, and the 
spleen correspondingly augmented. 

Treatment. — In the early stage begin treatment with a stimulating emetic, 
say lcbelia comp. Then follow with a warm bath, stimulating friction over the 
abdomen. If the vomiting is persistent, give : 

#-Syr. Rhei et Potass 3 ii. 

Tr. Cimicifuga .. 5 i. 

Dose.— One teaspoonful every two hours. 

After the urgent symptoms are controlled, put the patient upon syr. hypo- 
phosphite comp., one-half to a teaspoonful, three or four times a day. Flannel 
next the skin, warm salt-water baths daily, and when vomiting is persistent, a 
spice plaster over the stomach. All the way through give the syr. rhei et 
potass, in small doses. Avoid all the domestic nostrums — Godfrey's cordial, 
chalk mixture, etc. 

In the early stage, when there is much gastric disturbance, milk is apt to 
form tough clots and severely aggravate the inflammation. The mucilaginous 
drinks should therefore be substituted. But when this acid condition of the 
stomach subsides, then nothing is so well adapted as the mother's milk. At a later 



324 Principles and Practice of 

period, sago, tapioca, and other farinacious articles, may be preferable. Ex- 
treme debility supervening, a little raw meat juice or beef tea may be 
allowed. 



CHOLERA. 



Asiatic or epidemic cholera, originates in a peculiar, specific poisoning. This 
poison may be conveyed to a great distance by the wind, and be absorbed in the 
form of particles or atoms, which when inhaled or taken up by the absorbents, 
are capable of producing specific effects. This is one of the most terrible epi- 
demics visited upon the human race of this day in the civilized world, and the 
very fact of its fatality adds to its effects upon many persons. The poison 
seems to operate upon the nervous system, brain and spinal cord. This is 
proved by the prostration, coldness and livid appearance of the surface ; also 
we have vomiting, purging and suppression of urine, cramps of the abdominal 
muscles, cold extremities, and cramping in the limbs, sometimes preceded by di- 
arrhoea, but more frequently comes on without premonition. 

Symptoms. — -The symptoms of the disease, though it runs its course in a 
short time presents three stages : 

1. Countenance pale, irritability, languor, sleepiness, confusion of head, 
stomach deranged, nausea, vomiting, diarrhceal discharge. These are symp- 
toms or evidence-that nature is endeavoring to throw off some morb : d poison 
from the blood, and, if aided at this stage, we should never have the second. 

2. In which we have an aggravation of all in the first. Constant diarrhoea, 
discharge light colored, assumes a serous, or white, flaky and rice water appear- 
ance ; the pupil is contracted and we have cramps, spasms, cold body, inter- 
mittent pulse. This stage lasts from two to forty-eight hours. Then we have the 
third. 

3. Attended by suppression of urine, prostration, collapse and death. 

The general symptoms of these three stages, in detail, may be summed up as 
copious vomiting, excessive and increasing diarrhoea — without pain — a watery 
discharge with particles resembling small flakes of skin, or a rice water dis- 
charge. We shall find upon analysis, large proportions of albumen and the 
component parts of the blood — iron, chloride of soda, important elements 
which are being drained out of the system. Cramp becomes more frequent 
and severe, drawing the muscles into cord-like masses. Pulse soft and quick- 
no to 120. The skin inelastic, cold, dry, smooth, leaden-colored ; temperature 
65 to 70 deg. — skin assumes almost a bluish aspect. The expression of the 
features is ghastly, eyeballs sunken, cold, clammy sweats, eyes glassy and va- 
cant, tongue cold, also the breath ; mucous membrane of the mouth assumes a 
cold, bluish appearance. Distress in the stomach, unquenchable thirst, burning 
at the upper part of the abdomen, urine suppressed, as also all other secretions ; 
spasms attack the heart, its vessels, and ramifications ; also, the respiratory 
and whole circulatory system. The nervous system becomes easily excited and 
we have a husky voice, whispering, and shrinking of the whole body, pinched 
features, contracted pupils. These symptoms continuing, the breathing be- 






American Medicine and Surgery. 325 

comes less frequen; ; the rough, hoarse and husky voice, becomes spasmodic' 
jerking out each word ; the pulse becomes thread-like and intermitting ; circu- 
lation arrested and lungs become paralyzed. Should the patient survive forty- 
eight hours and show signs of improvement, he may recover rapidly ; this we 
will feel assured of if the pulse rise ; the stools assume a more healthy form 
and respiration and circulation grow better. Improvement may be only tran- 
sient, and we have continued suppression of urine, contraction of pupil and 
death is preceded by intense spasmodic contraction, vomiting, shortness of 
breath, coma. 

In more favorable cases we have a sort of fever, follows gradually, subsiding 
in a few days, or the fever may assume a more severe type, giving rise to a low, 
collapsed condition of the patient, a contracted pupil, a thread-like pulse, and 
suppression of secretions, finally ending in death. 

The symptoms and pathology of this disease prove conclusively that the 
poison operates directly upon the spinal cord. This is fully demonstrated in 
the dissecting room, for in every case the spinal cord will be found highly in- 
flamed and congested, or entirely surrounded and compressed with pus. 

Diagnosis. — The diagnostic marks are well defined, copious secretions and 
accumulations in the stomach and bowels of a serous fluid, albuminous in its 
character, free from acid or alkalies, and having more the appearance of rice 
water than anything else. This fluid is discharged from the mouth and bowels 
without effort. We have from the beginning an arrest of all the natural secre- 
tions and excreta, as tears, bile, saliva, fasces, urine, perspiration, etc. The skin 
becomes cold and void of elasticity, appears wrinkled, ^nd assumes a leaden 
color, mucous membrane presents similar appearance, tongue and breath cold. 
The muscles are in a state of tonic or constant spasm — especially is this true 
of the lower extremities. The specific poison is a minute particle generated 
from animal matter during some peculiar condition of the atmosphere, and 
operates upon constitutions impaired by some depressing influence ; hence those 
who become despondent at its.approach fall its first victims. 

Treatment. — During the prevalence of cholera in Philadelphia, some years 
ago, the superiority of the American practice over that of the old school, was 
fully demonstrated — in fact there is not an instance on record where such suc- 
cess attended the treatment of cholera as did our school then. When this epi- 
demic prevails a high standard of health should be maintained, individually and 
collectively. All green fruits and vegetables, hard or indigestible articles of 
diet, should be scrupulously avoided. No uncleanliness of premises and the 
most rigid bathing and washing of the person ; no intemperance, or fatigue, or 
over-exertion ; no breathing of vitiated air ; pure water ; the most nutritious 
and wholesome diet. 

Upon the slightest appearance of nausea, vomiting or diarrhoea, give the 
neutralizing mixture, one tablespoonful with leptandrin two grains, and ten 
drops of fluid ext. xanthoxylum, every half hour till relieved. 

Should the slightest indisposition exist, give the neutralizing mixture, with 
the leptandrin. 



~ 2 6 Principles and Practice of 

Perfect rest in the recumbent position is advisable. Apply capsicum and 
vinegar to the abdomen, proportioned as follows : 

Si. 

Ffc.— Pul. Cayenne Pepper g it 

Table Salt '/'. oi. 

Vinegar 

Give, as a drink, the infusion of bark of white mulberry, or slippery elm, and 

bayberry, thus : 

5 ii 
#.— Baberry (bark of root) g gs / 

Slippery Elm .. O i. 

Aqua 

Dose.— One wineglassful every two hours. 

Plain, nutritious diet is of the greatest importance, as, also, perfect rest. If 
we have the disease fairly set in we should place the patient in the most com- 
fortable part of the building, have an equitable temperature, say 80 deg., Fan. 
The diarrhoea and vomiting being but natural efforts to rid the system of the 
poison. A good plan will be to give a stimulating emetic, as : 

5 ii. 
fy— Pul. Green Lobelia 3 ^ 

" Bayberry '.'.'.'.'.'.'. 3- ss". 

" Capsicum 

Mix —Steep in a pint of boiling water, and give a teaspoonful every fifteen 
minutes until the patient vomits freely. Then follow with the neutralizing 
mixture, leptandrin and bavberry, as directed before. 

Get up a healthy secretion of the liver ; perfect rest. Apply the pepper sauce 
to stomach and abdomen, and apply oil of turpentine on each side of the spine. 
Opium, in any form, is* to be strictly prohibited, as it tends to increase the 
congestion of the spinal cord. The following is of great value in the early 

stage : 

#.— Fid. Ext. Papaver 5 ( y 

Aqua 

Mix, and give a tablespoonful, with sugar and water, twice a day. 
Should the pupil continue contracted, and cramp, or spasm be threatening, 
give the following : 

J^fc— Tine. Lobelia I '_ 

" Capsicum " ' ( 5 ii 

" Cypripedium J ^ ^ ' 

" Lactuca 

Dose.— One teaspoonful in wineglass of water every half hour. 

Should there be evidence of sinking, give one drop of oil of capsicum in 
sweetened water. Keep the counter-irritants applied to the spine. 

Give well-salted meat juice, relieve the thirst with iced champagne. 

When vomiting is incessant, both medicine and drink may be given every 
few minutes. If there is much heat or burning, we might give the sulphite of 
soda, with good effect. Maintain the recumbent position. 

Keep down the spasm with the remedies indicated, keep up a normal heat 
with hot sand bags, hot bricks, etc. Keep the bed away from the wall ; put 
pieces of glass under the bedstead legs, or rollers, and keep the air pure in the 
apartment, by removing all excreta as fast as possible, and use chloride of lime 
about the room as a disinfectant. 



American Medicine and Surgery. 327 

Convalescence should be established on mineral acids, etc. 

Acid nitro- muriatic, dil., twenty drops in water three times a day, with cin- 
chona comp., after meals. Shower baths and counter-irritants should be con- 
tinued. Many of these suggestions will hold good in severe forms of cholera 
morbus or dysentery. Did we pay more attention to hygienic laws, we should 
have less of disease, especially of summer bowel derangements. 



COLICA, OR COLIC. 

FLATULENT COLIC. 

Much of what is said of this form, equally applies to the two others. 

Pathology. — The disease may be seated in any portion of the alimentary canal, 
though its principal location is about the ileo-coecal valve. Commencing in sim- 
ple spasm of the muscular coat, it invariably terminates if long continued in 
inflammation. This may be confined to the muscular tissue, or it may involve 
the others. 

The pain has been generally attributed to spasm, but more correctly to the 
flatulent distension. 

The immense formations of gas are ascribeable in some instances to the de- 
composition of the intestinal contents, and in others to its secretion by the 
mucous membrane. 

Symptoms. — Sickness of stomach, spasmodic pains, flatulent distension, 
rumbling, twisting around the naval, and occasionally cramps of the abdominal 
muscles, and of those of the lower extremities, and unrelenting constipation. 
The vomiting is sometimes violent, the substance discharged may finally be 
stercoraceous. The pulse, at first little changed, soon becomes feeble and the 
surface cold. Should inflammation occur, the pulse is hard and corded, the 
temperature of the body very unequal, and the abdomen tender. 

If relief be not afforded, this state is succeeded by a return of the diminu- 
tive pulse, cold, damp skin, abatement, or cessation of the pain, a haggard 
countenance, singultus, and the other signs of approaching dissolution. 

Causes. — Indigestible articles of food, the vinous or alcoholic liquors, collec- 
tions of indurated faeces. Exposure to cold, and particularly when followed by 
a meal during the chill. 

Sympathy with distant parts. Lesions of the spinal marrow. The stomach 
and intestines sometimes acquire an extraordinary irritability. 

Diagnosis. — To distinguish the stercoracious vomiting proceeding from an 
intussusception of the intestine, from that proceeding from an inverted peris- 
taltic action without an intussusception, is impossible. 

Colic is diagnosticated from enteritis by the paroxysmal and spasmodic na- 
ture of the pain, the relief at first afforded on pressure, and by the flatulence 
and correspondent intumescence. But to hernia it is very analogous, both in 
the early and late stages. In doubtful cases, an examination should always be 
made. 



328 Principles mid Practice of 

Prognosis. — Colic is for the most part easily managed. The ejection of ster. 
coraceous matter is an almost fatal sign. 

Post Mortem. — The intestine distended with flatus, ingesta, or fasces. It is 
sometimes alternately contracted and dilated, exhibiting a series of pouches. 

The case being of long continuance with manifestation of jgpasm we meet 
with the marks of inflammation and occasionally with intussusceptions. The 
last are sometimes accompanied with gangrene, though more generally by no 
lesion whatever. 

Many of them are probably formed at the point of death. They occur 
chiefly in the ileum. The upper is mostly received into the lower portion, knots 
in the intestine are also sometimes formed. The stomach occasionally par- 
ticipates in the spasm, and it, together with the parietal peritoneum and liver, 
may be found in a state of inflammation. 

Treatment. — The indications of cure are to relax spasm and restore the 
peristaltic action. Warm water is a valuable remedy, warm fomentations, 
enemas of warm water. 

The warm bath is worthy of the most scrupulous attention, and should never 
be lost sight of, to relax abdominal spasm. The soothing effect of warm water 
upon the nervous system, when in a state of unnatural erethism, is too valuable 
to be neglected. 

Whatever may be the form of colic, give : 

P— Fid. Ext. Lobelia ) aa. 

" " Dioscorea V — 

" " Aselepias J 3 i. 

Dose. — Half teaspoonful in warm water, and repeat every fifteen minutes 
until free emesis. Follow with anti-spasmodic mixture : 

Jpk— Tr. Lobelia 5 ii. 

" Capsicum | aa. 

" Cypripedium , > — — 

" Scutelaria J S ii. 

Dose. — One teaspoonful in a tablespoonful of water, and give a mild saline 
purgative — seidlitz powder will meet the indications fully. 

BILIOUS COLIC. 

Pathology. — The chief point of dispute is, whether the liver is preternaturally 
excited, or depressed into torpor. There is, however, every reason to believe 
that in the advanced stage it becomes torpid. The nervous and cerebral dis- 
turbance may be either original or secondary. 

Symptoms. — The attack is occasionally preceded by the evidences of hepatic 
derangement. At other times it comes on with a chill followed by fever, at- 
tended with more or less perturbation of the alimentary canal, characteristic of 
colic. But it is as frequently introduced by violent vomitings. Bile is rarely 
thrown up in the commencement ; is thrown up very copiously after a while, 
and ceases at a still more advanced period, owing to a torpor of the liver from 
over-excitement. The retching, however, still continues. Whatever may have 
been the mode of commencement, the pulse gradually rises till it acquires much 
force and volume. 



American Medicine and Surgery. 329 

Sometimes, when the aggression is very violent, no reaction takes place, and 

' the collapse may be as complete as that in malignant cholera. Excruciating 

pain about the umbilicus, acute or dull pain in the head, and often depravation 

of vision, mind occasionally affected, and at times nervous tremors, or paralysis 

of the upper extremities. 

Causes. — Tl%e cause is autumnal fever, irritating ingesta, and spasmodic 
influence. 

Diagnosis. — Distinguish from other colic principally by the biliary derange- 
ment, and the fullness and activity of the pulse. 

Prognosis. — Pretty much like that of flatulent colic. Very favorable is the 
reappearance of bile after its suppression, and most unfavorable, of course, is 
the want of reaction. 

Post Mortem. — Much like that of flatulent colic. The liver is disordered, 
particularly by congestion. The stomach and intestines are more affected by 
inflammation than in the other variety. 

Treatment. — In this form colic will not differ materially from that of flatu- 
lent colic. If in children, give : 

Ipfc— Neutralizing Mixture 5 ii. 

Oil Anise ] aa. 

Ess. Peppermint J gtts. x. 

Mix, and give at a dose. In bilious colic in adults, in addition to the lobelia 
comp., as directed under the head of flatulent colic, we should give : 

J£fc— Podophyllin grs. ii. 

Bitartrate Potass -. 3 i. 

Give in a wine glass of cayenne pepper infusion. 

LEAD COLIC. 

Pathology. — Rather uncertain. The best opinion at present seems to be that 
the disease is a modified neuralgia, particularly of the spinal and sympathetic 
nerves, the irritation of which when intense and enduring, sometimes leads to 
inflammation. 

Symptoms. — Coming on gradually, nothing may at first be complained of, 
except a general feeling of wretchedness, uneasiness in the epigastrium and 
right hypocohndrium, indigestion, and constipation. Or without these premoni- 
tions, the disease may at once commence with pain at the pit of the stomach, 
descending to the intestines, a twisting sensation around the navel, nausea, ob- 
stinate constipation, and frequent though ineffectual desires to go to stool. The 
pain soon increases in violence, and the abdomen becomes exquisitely tender. 
The muscles of the abbomen and the lower limbs contract in hard knots, and 
there is incessant vomiting. Some cases much resemble dysentry. In most in- 
stances, paralytic affections supervene. It scarcely ever lasts less than five days 
and may continue for months. 

When the disease becomes decidedly chronic, the nutritive process is greatly 
vitiated, emaciation ensues, the countenance is sallow or leaden, the secretions 
are diminished, and the mind is very irritable, ■ or imbecile, and thus the affec- 



330 Prificiples and Practice of . 

tion proceeds, until usually it settles down into invincible palsy of the inferior 
though oftener of the upper extremities. It may also terminate in mania epi- 
lepsy, loss of some of the senses, or dropsy. 

Causes. — The internal use of the preparations of lead, or an external ex- 
posure to them. Thus persons have contracted the disease from eating things 
contained in a leaden or glazed jar, from drinking liquors impj|gnated with 
some saturnine preparation, possibly, in some instances, from drinking water 
which had been conducted through leaden pipes, from living in the vicinity of 
lead works, or even from living in rooms recently painted. It is ascertained 
that the carbonic acid commonly contained in water, will act upon the pure 
metal. 

The affection which has been ascribed to some other metals, and also the 
causes are already detailed as productive of the other kinds of colic. But it is 
probable that in the instances in which this reference was made there was either 
some unthought of exposure to lead, or the disease was really bilious colic. 
The use of canned fruit, tomatoes, etc., put up in cheap tins in which lead en- 
ters into the composition, is a fruitful source of lead colic. 

Diagnosis. — Distinguished from bilious colic by the unexcited condition of 
the pulse, the absence of very marked biliary disorder, the tendency to paralysis, 
and the mode of origin, and blue or purplish hue of the gums. 

Prognosis. — The cure is readily effected in recent cases, but old and compli- 
cated ones may be deemed doubtful. 

Post Mortem. — The reports of morbid anatomists on this subject are very 
inconsistent. Paris, Roche and Sanson declare that they found the intestines 
contracted at several points with a hard, dry matter, the intervals and the 
mucous membrane reddened, thickened and ulcerated. 

Treatment. — In the treatment of lead colic, the first indication is to relieve 
spasms with lobelia, comp. internally and per rectum, fomentations of the 
same locally, followed with an active cathartic, a warm bath of sulphuret of 
potassium, keeping the patient in it over half an hour. Great benefit is 
derived from this all through the case. Should these means fail the following 
should be tried : 

J^t— Sulphate Magnesia g iss. 

Sulphuric Acid, Dil g iii. 

Infusion of Wild Yam g x. 

Mix. — Dose. — Two tablespoonfuls once in three hours. 

Just as soon as possible five grain doses of iodide of potassium should be 
given every three hours, in a tablespoonful of comp. syr. stillingia. This sets 
the nominal poison free, and causes its rapid elimination by the secretions of 
the body. A chemical antidote is alum, which has a remarkable property of 
converting the salts of lead in the body to an innocent sulphate. If the pain is 
excruciating thirty drops of fluid ext. papaver should be given occasionally. 

Occasionally has the application of electricity been useful in palliating the severe 
symptoms; it is excellent in connection with the sulphuret of potassium baths 
when the urgency of the attack has been relieved. The best plan is to depend 



> • 



American Medicine and Surgery. 331 

upon the continued use of iodide of potassium for a free elimination of the 
poison. 

As a prophylactic five grains iodide potass, three times a day in the alterative 
syrup. 



INTESTINAL WORMS. 

Various are the opinions concerning the origin and formation of worms in the 
intestinal canal. It does not appear that they are received from without, because 
they are never found out of the animal body, and when removed out of the 
body they speedily die ; and lastly, earth worms and such as live in water, do 
not change their forms when received into the intestinal canal. There are five 
varieties of intestinal worms. 

1. TRICOCEPHALUS DISPAR. 

These worms are from an inch and a half to two inches in length. About 
two thirds of their length is almost as thin as a a horse hair, the remaining and 
posterior part being considerably thicker, and terminating in a rounded extremity. 
They are found principally in the ccecum. They are seldom numerous. 

2. ASCARIS VERMICULARIS. 

These are exceedingly short — not more than two lines in length, very thin 
and white. Their usual seat is in the rectum. 

3. ASCARIS LUMBRICOIDES. 

, These worms are from two or three to ten or twelve inches in length, round, 
of yellowish white, or brownish red color, of nearly a uniform thickness, except 
at the extremities, which taper to a blunt point. They are from two to three 
lines in thickness. They inhabit the small intestines chiefly, but occasionally 
ascend into the stomach. 

4. TVENIA LATA. 

This worm often acquires a very great length — from twenty to thirty feet and 
more ; it is from four to six lines in breadth, flat and white, resembling a piece 
of white tape, and composed of a series of concatenated joints. It inhabits 
the upper portion of the bowels and stomach. The head is armed with two 
processes by which the worm attaches itself to ths intestines. 

5. TAENIA SOLIUM. 

This worm is rarely, if ever, voided whole ; it generally passes off in short 
joints, resembling in some measure the seeds of gourd. Pieces, however, up- 
wards of twenty feet of this worm have been voided. The head is small and 
furnished with four small apertures. It inhabits the small intestines chiefly. 

Symptoms. — Countenance pale, lead colored, with occasional transient flushes, 
eyes dull, pupils dilated with a bluish semicircle around the lower eye-lids, tick- 
ling in the nose, tumid upper lip, occasional headache, and humming in the 



332 Principles ana Practice of 

ears ; copious secretions of saliva, tongue slimy or furred, breath foul, variable 
appetite, being sometimes voracious at others wholly gone ; transient pains in 
the stomach, occa?ional nausea and vomiting, pains in the abdomen, particu- 
larly about the umbilical region, frequent slimy stools, or costiveness, urine 
turbid, yellowish or milky, abdomen tumid and hard, with emaciation of the 
other parts of the body, lassitude, irritability of temper. 

None of these symptoms, however, are certain indications of the existence of 
worme in the bowels, the only certain indication being the appearance of them 
in the evacuations from the bowels or stomach. 

The opinion which is expressed by some that worms are harmless in the in- 
testinal canal, is without foundation. It is nevertheless probable that thai pecu- 
liar condition of the alimentary canal which favors the production of worms is 
more frequently the cause of mischief than the worms themselves. 

Worms give rise to a variety of affections, such as chorea, epilepsy, hydro- 
cephalus, emaciation, convulsions, paralysis, and a vast variety of anomalous 
disorders. 

Treatment. — In the treatment of worms, great attention should be paid to the 
general health, clothing, bathing, diet, hygiene ; no pork or saccharine agents 
allowed. Remedies should be given to astringe the mucous membrane of 
stomach and bowels, as myrica, geranium and tonics, as comp. tinct. cin- 
chona and nitro-muriatic acid, to promote assimilation. This is important, for 
when we give remedies either for the destruction or expulsion of the worms, 
this preliminary treatment prevents their generation. Our remedies should 
then be directed according to the species of parasites intended to be expelled, 
and our remedies are either expulsive, destructive, chemical, or mechanical. 

For the Ascarides. — Enemas are of the greatest use ; an injection of a so- 
lution of table salt, myrica, podophyllum, aloes, lime water, and camphor. 

INTERNAL TREATMENT. 

For the Lumbricoides. — Our best drug is santonine. Santonine and podo- 
phyllum, santonine and salacine. In the use of santonine for the chemical de- 
struction of this worm, care should be taken to observe that it is of a pure 
white color, not yellow ; it should be given in small doses, one to two grains at 
bed-time followed in the morning with a dose of comp. syr. rhubarb and potass. 
Small doses, as above indicated, are best for children, as santonine in large doses, 
is very irritating to the liver, besides its action as a vermifuge ; it is, perhaps, 
the most bracing tonic promotor of assimilation in the materia medica. 

In tape worm I have found the oil of pumpkin seed, male fern and turpen- 
tine, the most admirable combination ever introduced, followed by an active ca- 
thartic of podophyllum and leptandria. An infusion or extract of kousso may be 
used with advantage ; kameela is excellent. The following is a good formula 
for the expulsion of tape worm : 

]pfc— Kousso ") aa. 

Kameela > 

Pomegranate Root Bark ) Si. 

Pulv. Ergot 5 ii. 

Mix. — Add one ounce to half pint of boiling water ; when cool, take in two 



American Medicine and Surgery. 333 

doses, including sediment and all. Prior to the use of the above, the patient 
should fast for a day or more. The above prescription rarely fails to cause 
entire expulsion. The combined agents produce asphyxia of the parasite. 



INTESTINAL DISEASE. 

Obscure intestinal diseases are apt to baffle even the most skillful physicians, 
and the symptoms are so near those existing in other diseases, that we are often 
at a loss to determine or locate them. The diseases of a prominent nature, or 
well defined symptoms are mentioned under their regular head. We occasion- 
ally meet with calcareous deposits in the intestines, and when we do 
meet with them, they are usually a deposit of lime, soda. When the pains are 
such as to cause us to suspect this, we should resort to relaxation ; give lobelia, 
sanguinaria, etc., and when sufficiently relaxed, give an active purgative, under 
which the deposit will be expelled. Obstruction to the free passage of the in- 
testines may arise from a variety of causes — hernia, cancer, tumor in the bow- 
els, stricture, contraction from healing of ulceration after typhoid fever, etc., 
foreign bodies, concretion, etc. 1 

Symptoms.— Constipation, constant vomiting of mucus, then the contents of 
the stomach and bowels, followed by prostration and peritoneal inflammation. 

Treatment. — Place the patient under the influence of the following : 

R— Fid . Ext. Cypripedium g ss. 

Tinct. Lobelia . g i. 

Dose. — Thirty to sixty drops every two hours. Apply over the abdomen 
poultices of the herb of belladonna, inject the bowels with warm water, to which 
add a teaspoonful of tinct. lobelia and twenty drops of fld. ext. papaver. The 
intestines sometimes get drawn in, one part in over another, like the finger of a 
glove drawn in ; this will cause obstruction and congestion — ulceration and 
sloughing may ensue. 

The treatment recommended above is about all we can do in these cases. 
The symptoms are intense pain, vomiting, obstinate constipation, discharge of 
mucus and blood from the bowels. 



DISEASES OF THE RECTUM. 

The veins of the rectum are very tortuous and numerous, and owing to loca- 
tion, etc., are very subject to disease, due to congestion of vessels. Hemor- 
rhoids are most common, and are usually due to constipation and congestion in 
the first place. This trouble can be prevented by avoiding constipation on the 
one hand and drastic purgatives on the other. 

Protapsus of the rectum is sometimes met W'th and is the result of straining 
or griping, either from diarrhoea or drastic medicine, and is best corrected by 
warm water baths with a little hamamelis and myrica in the same. It is most 
common to children, and is only severe when inflammation results from protru- 
sion. 



334 Principles and Practice of 

Stricture of the rectum may be partial or complete ; is always more or less 
troublesome. 

1 Symptoms. — Constipation, the bowels are evacuated with difficulty, and in 
small particles. 

We have flatulence, pain in the bowels, mucous discharge, stained with 
blood, and the general health soon fails. 

Tr raiment. —To be successful must be of a mechanical nature, gradual dila- 
tation' Bougies of gutta percha, introduced daily and gradually increasing the 
size, leaving them in; say half an hour at a time. For spasmodic stricture use 
injection of fid. ext. lobelia and sanguinaria, twenty drops in a half pint of 
water. 



RECTAL ULCERATION. 

This is very often met with as a sequel of chronic or acute dysentery, and 
may occir ih connection with other diseases of the liver, lungs, etc. 

Symptoms. — We have a mixture of blood, mucus and purulent matter in 
each stool ; pain under the sacrum, and pubes during evacuation. Most fre- 
quent in women. 

Treatment.— Mild aperient to prevent constipation ; cod liver oil, nourishing 
food, no stimulants, and a tonic course to improve the general health. Keep 
the parts well cleansed with the solution of permanganate of potassa. 



RECTITIS, OR INFLAMMATION OF RECTUM. 

This is sometimes met with. 

Symptoms.— Heat and pain at the anus, extending under the sacrum ; fre- 
quent desire to go to stool, straining without passing anything but mucus or 
lymph, fearful pain when anything passes. 

Treatment. — Use mild injections of glycerine, slippery elm water, and a few 
drops of lobelia in each syringeful. Apply cold water externally, and give fif- 
teen drops fid. ext. asclepias every two hours. 

Chronic rectitis sometimes remains aftej an acute attack, and may result in 
fistula, fissure, ulceration, ect., always painful. 

Tre